1,HOSPITAL_NAME,LAST_UPDATED_ON,VERSION,HOSPITAL_LOCATION,HOSPITAL_ADDRESS,LICENSE_NUMBER|NM,"TO THE BEST OF ITS KNOWLEDGE AND BELIEF, THE HOSPITAL HAS INCLUDED ALL APPLICABLE STANDARD CHARGE INFORMATION IN ACCORDANCE WITH THE REQUIREMENTS OF 45 CFR 180.50, AND THE INFORMATION ENCODED IS TRUE, ACCURATE, AND COMPLETE AS OF THE DATE INDICATED.",,,,,,,,,,,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2,SIERRA VISTA HOSPITAL,07/25/2025,2.0.0,SIERRA VISTA HOSPITAL|SVH,"800 E 9TH ST, TRUTH OR CONSEQUENCES, NM 87901",321300,TRUE,,,,,,,,,,,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3,DESCRIPTION,CODE|1,CODE|1|TYPE,CODE|2,CODE|2|TYPE,CODE|3,CODE|3|TYPE,CODE|4,CODE|4|TYPE,MODIFIERS,SETTING,DRUG_UNIT_OF_MEASUREMENT,DRUG_TYPE_OF_MEASUREMENT,STANDARD_CHARGE|GROSS,STANDARD_CHARGE|DISCOUNTED_CASH,PAYER_NAME,PLAN_NAME,STANDARD_CHARGE|NEGOTIATED_DOLLAR,STANDARD_CHARGE|NEGOTIATED_PERCENTAGE,STANDARD_CHARGE|NEGOTIATED_ALGORITHM,ESTIMATED_AMOUNT,STANDARD_CHARGE|METHODOLOGY,STANDARD_CHARGE|MIN,STANDARD_CHARGE|MAX,ADDITIONAL_GENERIC_NOTES 4,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 977.50,,OUTPCT LIMIT, 920.20,OTHER, 507.84, 1127.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 722.50,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1168.75,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 12,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 13,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 14,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 15,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 16,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 17,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 18,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 19,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 20,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 21,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,BCBS,BLUE CROSS BLUE SHIELD, 413.78,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,BCBS,BLUE CROSS BLUE SHIELD, 413.78,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 234.81,,OUTPCT LIMIT, 168.89,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 198.90,,OUTPCT LIMIT, 171.36,OTHER, 103.33, 229.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,BCBS,BLUE CROSS BLUE SHIELD, 417.55,,OUTPCT LIMIT, 273.87,OTHER, 142.76, 481.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 373.15,,OUTPCT LIMIT, 276.81,OTHER, 142.76, 430.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 28,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,BCBS,BLUE CROSS BLUE SHIELD, 307.79,,OUTPCT LIMIT, 242.16,OTHER, 155.70, 354.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 29,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 391.85,,OUTPCT LIMIT, 850.02,OTHER, 203.58, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 30,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 373.15,,OUTPCT LIMIT, 667.92,OTHER, 193.86, 1237.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 130.90,,OUTPCT LIMIT, 177.23,OTHER, 68.01, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 59.50,,OUTPCT LIMIT, 131.69,OTHER, 30.91, 267.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 107.95,,OUTPCT LIMIT, 116.49,OTHER, 56.08, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 518.50,,OUTPCT LIMIT, 405.48,OTHER, 256.74, 597.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 311.95,,OUTPCT LIMIT, 293.67,OTHER, 162.07, 359.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 206.55,,OUTPCT LIMIT, 216.69,OTHER, 107.31, 256.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 37,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 65.45,,OUTPCT LIMIT, 61.61,OTHER, 34.00, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 38,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 116.45,,OUTPCT LIMIT, 233.68,OTHER, 60.50, 456.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 39,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 177.65,,OUTPCT LIMIT, 158.67,OTHER, 92.29, 204.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 40,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 135.15,,OUTPCT LIMIT, 112.58,OTHER, 70.21, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 41,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 156.40,,OUTPCT LIMIT, 125.44,OTHER, 81.25, 180.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 42,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 99.45,,OUTPCT LIMIT, 114.17,OTHER, 51.67, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 43,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 117.30,,OUTPCT LIMIT, 122.15,OTHER, 60.94, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 44,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 178.50,,OUTPCT LIMIT, 138.81,OTHER, 86.20, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 142.80,,OUTPCT LIMIT, 117.21,OTHER, 74.19, 164.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 174.25,,OUTPCT LIMIT, 258.26,OTHER, 90.53, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 222.70,,OUTPCT LIMIT, 287.58,OTHER, 115.70, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 48,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 300.05,,OUTPCT LIMIT, 334.39,OTHER, 155.88, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 49,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2028.10,,OUTPCT LIMIT, 1514.68,OTHER, 804.50, 2338.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 50,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1145.80,,OUTPCT LIMIT, 1306.30,OTHER, 595.28, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 51,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 516.80,,OUTPCT LIMIT, 925.64,OTHER, 268.49, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 52,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 169.15,,OUTPCT LIMIT, 389.69,OTHER, 87.88, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 53,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 231.20,,OUTPCT LIMIT, 427.24,OTHER, 120.12, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 54,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 281.35,,OUTPCT LIMIT, 457.59,OTHER, 146.17, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 55,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 198.05,,OUTPCT LIMIT, 732.74,OTHER, 102.89, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 56,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 577.15,,OUTPCT LIMIT, 1168.49,OTHER, 299.85, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 57,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 243.95,,OUTPCT LIMIT, 300.44,OTHER, 126.74, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 58,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 343.40,,OUTPCT LIMIT, 495.14,OTHER, 178.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 59,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 408.85,,OUTPCT LIMIT, 534.75,OTHER, 212.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 60,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 471.75,,OUTPCT LIMIT, 572.81,OTHER, 245.09, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 61,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 420.75,,OUTPCT LIMIT, 541.95,OTHER, 218.59, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 62,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 481.95,,OUTPCT LIMIT, 578.99,OTHER, 250.39, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 63,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1475.60,,OUTPCT LIMIT, 1505.88,OTHER, 766.62, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 64,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 594.15,,OUTPCT LIMIT, 646.89,OTHER, 308.68, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 65,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 699.55,,OUTPCT LIMIT, 1242.56,OTHER, 363.44, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 66,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 373.15,,OUTPCT LIMIT, 513.14,OTHER, 193.86, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 67,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 385.90,,OUTPCT LIMIT, 520.86,OTHER, 200.49, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 68,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 673.20,,OUTPCT LIMIT, 694.73,OTHER, 349.75, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 69,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 553.35,,OUTPCT LIMIT, 947.76,OTHER, 287.48, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 70,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 948.60,,OUTPCT LIMIT, 1393.28,OTHER, 492.83, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 71,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 47.60,,OUTPCT LIMIT, 56.01,OTHER, 24.73, 76.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 72,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 287.22,,OUTPCT LIMIT, 185.53,OTHER, 86.20, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 73,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,BCBS,BLUE CROSS BLUE SHIELD, 109.89,,OUTPCT LIMIT, 97.29,OTHER, 57.09, 126.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 74,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 109.65,,OUTPCT LIMIT, 97.14,OTHER, 56.97, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 75,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 43.35,,OUTPCT LIMIT, 57.02,OTHER, 22.52, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 76,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 363.80,,OUTPCT LIMIT, 372.97,OTHER, 189.00, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 77,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1037.00,,OUTPCT LIMIT, 1446.78,OTHER, 538.75, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 78,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 499.80,,OUTPCT LIMIT, 1121.68,OTHER, 259.66, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 79,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,BCBS,BLUE CROSS BLUE SHIELD, 326.18,,OUTPCT LIMIT, 278.63,OTHER, 165.01, 383.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 80,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,BCBS,BLUE CROSS BLUE SHIELD, 585.51,,OUTPCT LIMIT, 427.61,OTHER, 296.20, 675.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 81,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,BCBS,BLUE CROSS BLUE SHIELD, 354.32,,OUTPCT LIMIT, 237.66,OTHER, 143.26, 408.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 82,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 382.16,,OUTPCT LIMIT, 253.66,OTHER, 143.26, 440.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 83,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 414.38,,OUTPCT LIMIT, 272.17,OTHER, 143.26, 477.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 84,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,BCBS,BLUE CROSS BLUE SHIELD, 378.22,,OUTPCT LIMIT, 251.39,OTHER, 143.26, 436.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 85,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 347.65,,OUTPCT LIMIT, 261.55,OTHER, 143.26, 400.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 86,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,BCBS,BLUE CROSS BLUE SHIELD, 401.13,,OUTPCT LIMIT, 264.56,OTHER, 143.26, 462.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 87,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,BCBS,BLUE CROSS BLUE SHIELD, 405.20,,OUTPCT LIMIT, 306.35,OTHER, 204.98, 467.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 88,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 723.35,,OUTPCT LIMIT, 548.12,OTHER, 309.01, 833.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 89,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 418.20,,OUTPCT LIMIT, 300.52,OTHER, 132.82, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 90,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,BCBS,BLUE CROSS BLUE SHIELD, 455.12,,OUTPCT LIMIT, 293.08,OTHER, 132.82, 524.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 91,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,BCBS,BLUE CROSS BLUE SHIELD, 1653.98,,OUTPCT LIMIT, 1023.77,OTHER, 309.01, 1906.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 92,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 640.90,,OUTPCT LIMIT, 498.22,OTHER, 309.01, 738.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 93,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,BCBS,BLUE CROSS BLUE SHIELD, 2784.82,,OUTPCT LIMIT, 1703.49,OTHER, 435.32, 3210.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 94,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 736.95,,OUTPCT LIMIT, 601.46,OTHER, 382.87, 849.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 95,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2297.55,,OUTPCT LIMIT, 2228.68,OTHER, 1193.64, 2648.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 96,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2495.60,,OUTPCT LIMIT, 2329.49,OTHER, 1296.54, 2877.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 97,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 108.80,,OUTPCT LIMIT, 163.86,OTHER, 56.52, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 98,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 287.22,,OUTPCT LIMIT, 200.99,OTHER, 145.30, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 99,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 102.85,,OUTPCT LIMIT, 93.03,OTHER, 53.43, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 100,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 11.05,,OUTPCT LIMIT, 22.22,OTHER, 5.74, 43.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 101,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 282.20,,OUTPCT LIMIT, 224.77,OTHER, 146.61, 325.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 102,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 149.60,,OUTPCT LIMIT, 251.63,OTHER, 77.72, 451.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 103,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 464.95,,OUTPCT LIMIT, 1148.36,OTHER, 241.56, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 104,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1102.45,,OUTPCT LIMIT, 1534.16,OTHER, 572.76, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 105,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 235.45,,OUTPCT LIMIT, 232.01,OTHER, 122.32, 271.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 106,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 112.71,,OUTPCT LIMIT, 124.43,OTHER, 57.02, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 107,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 105.40,,OUTPCT LIMIT, 120.23,OTHER, 53.32, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 108,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 122.83,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 109,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 122.83,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 110,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 7247.10,,OUTPCT LIMIT, 5204.99,OTHER, 2293.79, 8355.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 111,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 528.70,,OUTPCT LIMIT, 932.84,OTHER, 274.68, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 112,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 671.67,,OUTPCT LIMIT, 424.57,OTHER, 162.56, 774.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 113,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,BCBS,BLUE CROSS BLUE SHIELD, 515.57,,OUTPCT LIMIT, 334.89,OTHER, 162.56, 594.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 114,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 981.61,,OUTPCT LIMIT, 675.88,OTHER, 470.23, 1131.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 115,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 802.57,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 116,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 802.57,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 117,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,BCBS,BLUE CROSS BLUE SHIELD, 294.14,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 118,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,BCBS,BLUE CROSS BLUE SHIELD, 294.14,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 119,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,BCBS,BLUE CROSS BLUE SHIELD, 264.75,,OUTPCT LIMIT, 176.70,OTHER, 103.34, 305.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 120,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 960.46,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 121,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 960.46,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 122,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,BCBS,BLUE CROSS BLUE SHIELD, 1671.05,,OUTPCT LIMIT, 1089.64,OTHER, 544.52, 1926.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 123,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 29.75,,OUTPCT LIMIT, 22.43,OTHER, 15.05, 34.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 124,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,BCBS,BLUE CROSS BLUE SHIELD, 26.39,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 125,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,BCBS,BLUE CROSS BLUE SHIELD, 26.39,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 126,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,BCBS,BLUE CROSS BLUE SHIELD, 26.39,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 127,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,BCBS,BLUE CROSS BLUE SHIELD, 26.39,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 128,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,BCBS,BLUE CROSS BLUE SHIELD, 26.39,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 129,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,BCBS,BLUE CROSS BLUE SHIELD, 26.39,,OUTPCT LIMIT, 20.38,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 130,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 21.25,,OUTPCT LIMIT, 16.02,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 131,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,BCBS,BLUE CROSS BLUE SHIELD, 870.49,,OUTPCT LIMIT, 579.04,OTHER, 331.58, 1003.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 132,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1875.10,,OUTPCT LIMIT, 1525.88,OTHER, 974.17, 2161.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 133,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 5304.00,,OUTPCT LIMIT, 4097.24,OTHER, 2484.68, 6115.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 134,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 5641.45,,OUTPCT LIMIT, 4480.28,OTHER, 2930.90, 6504.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 135,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 697.85,,OUTPCT LIMIT, 813.44,OTHER, 362.55, 1095.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 136,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 6113.20,,OUTPCT LIMIT, 4090.68,OTHER, 1095.12, 7048.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 137,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,BCBS,BLUE CROSS BLUE SHIELD, 205.35,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 138,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,BCBS,BLUE CROSS BLUE SHIELD, 205.35,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 139,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 537.20,,OUTPCT LIMIT, 1187.28,OTHER, 279.09, 2414.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 140,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 332.35,,OUTPCT LIMIT, 803.17,OTHER, 172.67, 1685.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 141,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1869.15,,OUTPCT LIMIT, 1733.21,OTHER, 971.08, 2155.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 142,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2398.70,,OUTPCT LIMIT, 1757.99,OTHER, 857.80, 2765.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 143,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 283.05,,OUTPCT LIMIT, 477.65,OTHER, 147.05, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 144,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 316.20,,OUTPCT LIMIT, 497.71,OTHER, 164.28, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 145,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1996.65,,OUTPCT LIMIT, 1514.68,OTHER, 857.80, 2302.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 146,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2821.15,,OUTPCT LIMIT, 2013.65,OTHER, 857.80, 3252.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 147,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 402.05,,OUTPCT LIMIT, 549.67,OTHER, 208.88, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 148,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 449.65,,OUTPCT LIMIT, 578.48,OTHER, 233.61, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 149,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2342.60,,OUTPCT LIMIT, 2205.29,OTHER, 1217.05, 2700.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 150,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2868.75,,OUTPCT LIMIT, 2700.60,OTHER, 1490.40, 3307.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 151,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,BCBS,BLUE CROSS BLUE SHIELD, 991.30,,OUTPCT LIMIT, 718.33,OTHER, 501.48, 1142.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 152,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2589.10,,OUTPCT LIMIT, 2437.34,OTHER, 1345.11, 2985.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 153,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1369.35,,OUTPCT LIMIT, 1780.93,OTHER, 711.42, 2666.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 154,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1274.15,,OUTPCT LIMIT, 2411.76,OTHER, 661.96, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 155,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 134.30,,OUTPCT LIMIT, 283.55,OTHER, 69.77, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 156,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 159.80,,OUTPCT LIMIT, 298.98,OTHER, 83.02, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 157,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 262.65,,OUTPCT LIMIT, 482.77,OTHER, 136.45, 906.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 158,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 470.90,,OUTPCT LIMIT, 603.90,OTHER, 244.65, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 159,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 551.65,,OUTPCT LIMIT, 652.77,OTHER, 286.60, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 160,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 719.10,,OUTPCT LIMIT, 754.11,OTHER, 373.59, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 161,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 656.20,,OUTPCT LIMIT, 716.04,OTHER, 340.92, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 162,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 632.40,,OUTPCT LIMIT, 701.64,OTHER, 328.55, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 163,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 3232.55,,OUTPCT LIMIT, 2366.55,OTHER, 1148.80, 3726.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 164,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 213.35,,OUTPCT LIMIT, 623.49,OTHER, 110.84, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 165,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 306.85,,OUTPCT LIMIT, 256.43,OTHER, 159.42, 353.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 166,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 236.30,,OUTPCT LIMIT, 637.38,OTHER, 122.76, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 167,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 236.30,,OUTPCT LIMIT, 982.61,OTHER, 122.76, 2350.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 168,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1259.70,,OUTPCT LIMIT, 1507.20,OTHER, 654.45, 2085.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 169,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 3181.55,,OUTPCT LIMIT, 3143.54,OTHER, 1652.91, 3668.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 170,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1397.40,,OUTPCT LIMIT, 2486.35,OTHER, 725.99, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 171,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1518.95,,OUTPCT LIMIT, 2559.90,OTHER, 789.14, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 172,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1513.85,,OUTPCT LIMIT, 1425.12,OTHER, 786.49, 1745.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 173,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2436.10,,OUTPCT LIMIT, 1667.02,OTHER, 539.71, 2808.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 174,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1101.60,,OUTPCT LIMIT, 1786.42,OTHER, 572.31, 3135.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 175,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 3010.70,,OUTPCT LIMIT, 3662.54,OTHER, 1564.15, 5153.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 176,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 311.10,,OUTPCT LIMIT, 889.66,OTHER, 161.63, 1963.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 177,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 342.51,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 178,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 342.51,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 179,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2315.40,,OUTPCT LIMIT, 2146.09,OTHER, 1202.92, 2669.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 180,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 199.77,OTHER, 96.75, 377.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 181,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 266.50,OTHER, 96.75, 657.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 182,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2922.30,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 183,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2922.30,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 184,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,BCBS,BLUE CROSS BLUE SHIELD, 954.42,,OUTPCT LIMIT, 719.65,OTHER, 482.83, 1100.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 185,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,BCBS,BLUE CROSS BLUE SHIELD, 1707.27,,OUTPCT LIMIT, 1287.31,OTHER, 863.68, 1968.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 186,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 385.82,,OUTPCT LIMIT, 290.91,OTHER, 195.18, 444.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 187,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1439.90,,OUTPCT LIMIT, 2579.17,OTHER, 748.07, 4781.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 188,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,BCBS,BLUE CROSS BLUE SHIELD, 221.95,,OUTPCT LIMIT, 162.43,OTHER, 112.28, 255.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 189,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,BCBS,BLUE CROSS BLUE SHIELD, 192.17,,OUTPCT LIMIT, 145.32,OTHER, 97.21, 221.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 190,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 122.74,,OUTPCT LIMIT, 116.13,OTHER, 62.09, 191.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 191,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 101.15,,OUTPCT LIMIT, 76.24,OTHER, 51.17, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 192,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,BCBS,BLUE CROSS BLUE SHIELD, 181.10,,OUTPCT LIMIT, 124.60,OTHER, 86.34, 208.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 193,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 194,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.10,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 195,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 196,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 116.45,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 197,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 198,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,BCBS,BLUE CROSS BLUE SHIELD, 223.77,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 199,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 200,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.10,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 201,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 202,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,BCBS,BLUE CROSS BLUE SHIELD, 242.05,,OUTPCT LIMIT, 171.96,OTHER, 122.45, 279.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 203,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 204,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 186.58,,OUTPCT LIMIT, 127.74,OTHER, 86.34, 215.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 205,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 206,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,BCBS,BLUE CROSS BLUE SHIELD, 272.73,,OUTPCT LIMIT, 189.58,OTHER, 137.97, 314.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 207,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 208,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,BCBS,BLUE CROSS BLUE SHIELD, 167.73,,OUTPCT LIMIT, 116.92,OTHER, 84.85, 193.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 209,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 210,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,BCBS,BLUE CROSS BLUE SHIELD, 464.13,,OUTPCT LIMIT, 299.54,OTHER, 138.19, 535.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 211,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 212,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,BCBS,BLUE CROSS BLUE SHIELD, 327.49,,OUTPCT LIMIT, 221.04,OTHER, 138.19, 377.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 213,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 214,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 251.60,,OUTPCT LIMIT, 177.44,OTHER, 127.28, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 215,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 216,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,BCBS,BLUE CROSS BLUE SHIELD, 88.17,,OUTPCT LIMIT, 71.21,OTHER, 44.60, 101.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 217,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 218,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,BCBS,BLUE CROSS BLUE SHIELD, 301.14,,OUTPCT LIMIT, 193.56,OTHER, 86.34, 347.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 219,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 220,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 353.26,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 221,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,BCBS,BLUE CROSS BLUE SHIELD, 2488.92,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 222,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,BCBS,BLUE CROSS BLUE SHIELD, 1850.01,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 223,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 224,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 225,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 1902.81,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 226,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 1902.81,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 227,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 228,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 229,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,BCBS,BLUE CROSS BLUE SHIELD, 2488.92,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 230,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,BCBS,BLUE CROSS BLUE SHIELD, 2488.92,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 231,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 232,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 233,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,BCBS,BLUE CROSS BLUE SHIELD, 1545.07,,OUTPCT LIMIT, 955.20,OTHER, 283.82, 1781.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 234,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 235,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,BCBS,BLUE CROSS BLUE SHIELD, 1024.30,,OUTPCT LIMIT, 691.35,OTHER, 432.18, 1180.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 236,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 237,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1343.00,,OUTPCT LIMIT, 887.08,OTHER, 485.27, 1548.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 238,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 239,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1450.95,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 240,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,BCBS,BLUE CROSS BLUE SHIELD, 1451.27,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 241,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 242,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 243,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 1658.92,,OUTPCT LIMIT, 1055.93,OTHER, 432.18, 1912.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 244,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,BCBS,BLUE CROSS BLUE SHIELD, 2088.44,,OUTPCT LIMIT, 1302.68,OTHER, 432.18, 2407.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 245,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 246,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 247,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 691.90,,OUTPCT LIMIT, 513.03,OTHER, 350.02, 797.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 248,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 249,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,BCBS,BLUE CROSS BLUE SHIELD, 2128.88,,OUTPCT LIMIT, 1290.59,OTHER, 283.82, 2454.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 250,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 251,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,BCBS,BLUE CROSS BLUE SHIELD, 2214.00,,OUTPCT LIMIT, 1374.81,OTHER, 432.18, 2552.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 252,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 253,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 2002.52,,OUTPCT LIMIT, 1265.96,OTHER, 485.27, 2308.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 254,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 255,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 1667.91,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 256,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 1667.91,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 257,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 1667.91,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 258,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 259,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 260,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 261,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 2006.77,,OUTPCT LIMIT, 1270.81,OTHER, 495.38, 2313.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 262,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 263,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 2604.12,,OUTPCT LIMIT, 1681.52,OTHER, 779.04, 3002.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 264,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 265,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,BCBS,BLUE CROSS BLUE SHIELD, 1921.33,,OUTPCT LIMIT, 1224.87,OTHER, 508.57, 2215.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 266,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 267,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2049.35,,OUTPCT LIMIT, 1324.21,OTHER, 616.91, 2362.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 268,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 269,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 2345.58,,OUTPCT LIMIT, 1532.99,OTHER, 779.04, 2704.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 270,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 271,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 1936.51,,OUTPCT LIMIT, 1233.59,OTHER, 508.57, 2232.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 272,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 273,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1931.20,,OUTPCT LIMIT, 1256.33,OTHER, 616.91, 2226.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 274,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 275,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 2220.41,,OUTPCT LIMIT, 1461.09,OTHER, 779.04, 2560.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 276,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 277,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,BCBS,BLUE CROSS BLUE SHIELD, 2249.96,,OUTPCT LIMIT, 1413.66,OTHER, 508.57, 2594.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 278,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 279,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,BCBS,BLUE CROSS BLUE SHIELD, 3473.88,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 280,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,BCBS,BLUE CROSS BLUE SHIELD, 3473.88,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 281,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 282,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 283,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.10,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 284,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.10,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 285,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.10,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 286,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.10,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 287,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 288,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 289,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 290,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 291,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.10,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 292,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 293,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.10,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 294,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.10,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 295,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 296,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 297,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,BCBS,BLUE CROSS BLUE SHIELD, 385.55,,OUTPCT LIMIT, 242.05,OTHER, 86.34, 444.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 298,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,BCBS,BLUE CROSS BLUE SHIELD, 388.10,,OUTPCT LIMIT, 243.52,OTHER, 86.34, 447.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 299,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 300,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 301,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,BCBS,BLUE CROSS BLUE SHIELD, 315.47,,OUTPCT LIMIT, 214.14,OTHER, 138.19, 363.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 302,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,BCBS,BLUE CROSS BLUE SHIELD, 360.54,,OUTPCT LIMIT, 240.03,OTHER, 138.19, 415.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 303,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 304,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 305,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,BCBS,BLUE CROSS BLUE SHIELD, 375.93,,OUTPCT LIMIT, 248.87,OTHER, 138.19, 433.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 306,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 307,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 251.60,,OUTPCT LIMIT, 165.10,OTHER, 86.34, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 308,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 309,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.10,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 310,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 311,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 1991.04,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 312,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 1991.04,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 313,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 1991.04,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 314,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 315,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 316,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 1991.04,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 317,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 2374.49,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 318,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 319,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,BCBS,BLUE CROSS BLUE SHIELD, 2962.13,,OUTPCT LIMIT, 1817.25,OTHER, 485.27, 3415.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 320,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 321,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 1991.04,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 322,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 1991.04,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 323,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 1991.04,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 324,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 325,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 326,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 327,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,BCBS,BLUE CROSS BLUE SHIELD, 4233.03,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 328,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 2852.33,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 329,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 2852.33,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 330,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 2852.33,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 331,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 2852.33,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 332,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 333,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 334,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 335,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 336,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1076.10,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 337,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2401.25,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 338,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 339,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 340,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 258.40,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 341,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 258.40,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 342,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 343,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 344,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,BCBS,BLUE CROSS BLUE SHIELD, 373.81,,OUTPCT LIMIT, 247.65,OTHER, 138.19, 430.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 345,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 346,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 553.01,,OUTPCT LIMIT, 350.60,OTHER, 138.19, 637.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 347,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 348,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,BCBS,BLUE CROSS BLUE SHIELD, 608.76,,OUTPCT LIMIT, 382.63,OTHER, 138.19, 701.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 349,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 350,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,BCBS,BLUE CROSS BLUE SHIELD, 453.61,,OUTPCT LIMIT, 293.50,OTHER, 138.19, 522.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 351,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 352,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,BCBS,BLUE CROSS BLUE SHIELD, 405.50,,OUTPCT LIMIT, 265.86,OTHER, 138.19, 467.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 353,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 354,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,BCBS,BLUE CROSS BLUE SHIELD, 223.77,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 355,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 356,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 212.50,,OUTPCT LIMIT, 142.64,OTHER, 86.34, 245.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 357,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 358,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.10,,OUTPCT LIMIT, 63.06,OTHER, 36.98, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 359,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,BCBS,BLUE CROSS BLUE SHIELD, 223.77,,OUTPCT LIMIT, 163.44,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 360,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 361,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 393.98,,OUTPCT LIMIT, 259.24,OTHER, 138.19, 454.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 362,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 363,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.26,,OUTPCT LIMIT, 166.91,OTHER, 118.00, 268.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 364,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 365,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,BCBS,BLUE CROSS BLUE SHIELD, 651.33,,OUTPCT LIMIT, 407.08,OTHER, 138.19, 750.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 366,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 367,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,BCBS,BLUE CROSS BLUE SHIELD, 2422.68,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 368,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,BCBS,BLUE CROSS BLUE SHIELD, 2422.68,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 369,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,BCBS,BLUE CROSS BLUE SHIELD, 2422.68,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 370,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 371,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 372,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 373,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 956.25,,OUTPCT LIMIT, 664.89,OTHER, 483.75, 1102.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 374,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 375,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,BCBS,BLUE CROSS BLUE SHIELD, 2752.95,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 376,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,BCBS,BLUE CROSS BLUE SHIELD, 2752.95,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 377,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 378,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 379,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2720.00,,OUTPCT LIMIT, 1665.51,OTHER, 432.18, 3136.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 380,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 381,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,BCBS,BLUE CROSS BLUE SHIELD, 2387.52,,OUTPCT LIMIT, 1439.18,OTHER, 283.82, 2752.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 382,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 383,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,BCBS,BLUE CROSS BLUE SHIELD, 2697.51,,OUTPCT LIMIT, 1652.58,OTHER, 432.18, 3110.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 384,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 385,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2550.00,,OUTPCT LIMIT, 1580.48,OTHER, 485.27, 2940.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 386,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 387,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,BCBS,BLUE CROSS BLUE SHIELD, 2769.78,,OUTPCT LIMIT, 1712.29,OTHER, 508.57, 3193.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 388,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 389,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,BCBS,BLUE CROSS BLUE SHIELD, 3087.44,,OUTPCT LIMIT, 1894.78,OTHER, 508.57, 3559.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 390,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 391,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 2709.97,,OUTPCT LIMIT, 1677.93,OTHER, 508.57, 3124.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 392,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 393,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 3367.02,,OUTPCT LIMIT, 2119.80,OTHER, 779.04, 3881.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 394,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 395,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,BCBS,BLUE CROSS BLUE SHIELD, 4097.65,,OUTPCT LIMIT, 2539.54,OTHER, 779.04, 4724.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 396,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 397,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,BCBS,BLUE CROSS BLUE SHIELD, 3837.70,,OUTPCT LIMIT, 2390.20,OTHER, 779.04, 4424.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 398,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 399,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 400,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 401,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 402,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,BCBS,BLUE CROSS BLUE SHIELD, 354.94,,OUTPCT LIMIT, 236.81,OTHER, 138.19, 409.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 403,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 404,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,BCBS,BLUE CROSS BLUE SHIELD, 280.19,,OUTPCT LIMIT, 193.87,OTHER, 138.19, 323.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 405,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 406,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,BCBS,BLUE CROSS BLUE SHIELD, 2077.65,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 407,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,BCBS,BLUE CROSS BLUE SHIELD, 2077.65,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 408,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 409,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 410,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 2007.36,,OUTPCT LIMIT, 1256.10,OTHER, 432.18, 2314.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 411,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 412,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 1356.18,,OUTPCT LIMIT, 894.65,OTHER, 485.27, 1563.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 413,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 414,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,BCBS,BLUE CROSS BLUE SHIELD, 2838.07,,OUTPCT LIMIT, 1751.53,OTHER, 508.57, 3272.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 415,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 416,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,BCBS,BLUE CROSS BLUE SHIELD, 4254.00,,OUTPCT LIMIT, 2629.35,OTHER, 779.04, 4904.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 417,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 418,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1700.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 419,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1700.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 420,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1700.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 421,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 422,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 423,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 424,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 250.01,,OUTPCT LIMIT, 164.19,OTHER, 86.34, 288.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 425,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 426,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,BCBS,BLUE CROSS BLUE SHIELD, 354.74,,OUTPCT LIMIT, 224.35,OTHER, 86.34, 408.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 427,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 428,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,BCBS,BLUE CROSS BLUE SHIELD, 327.51,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 429,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,BCBS,BLUE CROSS BLUE SHIELD, 327.51,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 430,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,BCBS,BLUE CROSS BLUE SHIELD, 339.70,,OUTPCT LIMIT, 215.71,OTHER, 86.34, 391.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 431,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 432,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 433,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 434,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,BCBS,BLUE CROSS BLUE SHIELD, 223.77,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 435,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,BCBS,BLUE CROSS BLUE SHIELD, 223.77,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 436,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,BCBS,BLUE CROSS BLUE SHIELD, 223.77,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 437,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 438,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 439,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 440,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 270.30,,OUTPCT LIMIT, 175.84,OTHER, 86.34, 311.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 441,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,BCBS,BLUE CROSS BLUE SHIELD, 258.49,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 442,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,BCBS,BLUE CROSS BLUE SHIELD, 258.49,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 443,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 444,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 445,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 446,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 351.90,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 447,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 351.90,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 448,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.11,,OUTPCT LIMIT, 240.36,OTHER, 138.19, 416.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 449,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 450,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 451,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 452,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,BCBS,BLUE CROSS BLUE SHIELD, 346.65,,OUTPCT LIMIT, 219.70,OTHER, 86.34, 399.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 453,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,BCBS,BLUE CROSS BLUE SHIELD, 337.51,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 454,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,BCBS,BLUE CROSS BLUE SHIELD, 337.51,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 455,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 456,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 457,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 458,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 323.77,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 459,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,BCBS,BLUE CROSS BLUE SHIELD, 332.90,,OUTPCT LIMIT, 211.81,OTHER, 86.34, 383.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 460,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 323.77,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 461,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 462,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 463,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 464,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 364.65,,OUTPCT LIMIT, 230.04,OTHER, 86.34, 420.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 465,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 353.26,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 466,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 467,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 468,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 469,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 366.01,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 470,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 366.01,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 471,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 377.40,,OUTPCT LIMIT, 237.37,OTHER, 86.34, 435.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 472,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 473,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 474,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 475,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 116.45,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 476,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 161.50,,OUTPCT LIMIT, 125.68,OTHER, 81.70, 186.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 477,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 116.45,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 478,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 479,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 480,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 481,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 336.26,,OUTPCT LIMIT, 213.73,OTHER, 86.34, 387.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 482,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,BCBS,BLUE CROSS BLUE SHIELD, 325.81,,OUTPCT LIMIT, 207.73,OTHER, 86.34, 375.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 483,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,BCBS,BLUE CROSS BLUE SHIELD, 325.82,,OUTPCT LIMIT, 207.74,OTHER, 86.34, 375.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 484,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 485,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 486,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 487,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 378.82,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 488,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,BCBS,BLUE CROSS BLUE SHIELD, 387.97,,OUTPCT LIMIT, 243.44,OTHER, 86.34, 447.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 489,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 378.82,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 490,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 491,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 492,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 493,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 357.85,,OUTPCT LIMIT, 238.48,OTHER, 138.19, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 494,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 346.46,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 495,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 346.46,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 496,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 497,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 498,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 499,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,BCBS,BLUE CROSS BLUE SHIELD, 347.79,,OUTPCT LIMIT, 220.36,OTHER, 86.34, 400.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 500,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,BCBS,BLUE CROSS BLUE SHIELD, 347.90,,OUTPCT LIMIT, 220.42,OTHER, 86.34, 401.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 501,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,BCBS,BLUE CROSS BLUE SHIELD, 357.03,,OUTPCT LIMIT, 225.67,OTHER, 86.34, 411.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 502,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 503,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 504,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 505,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 289.77,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 506,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,BCBS,BLUE CROSS BLUE SHIELD, 268.30,,OUTPCT LIMIT, 174.69,OTHER, 86.34, 309.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 507,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 259.17,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 508,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 259.17,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 509,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 259.17,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 510,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 259.17,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 511,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 259.17,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 512,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 259.17,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 513,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 259.17,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 514,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 259.17,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 515,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 259.17,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 516,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 259.17,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 517,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 259.17,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 518,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 519,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 520,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 521,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 522,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 523,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 524,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 525,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 526,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 527,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 528,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 529,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 530,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 531,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 1607.92,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 532,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 1729.34,,OUTPCT LIMIT, 1061.06,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 533,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 1729.34,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 534,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 1729.34,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 535,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 1729.34,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 536,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 1729.34,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 537,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 1729.34,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 538,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 568.65,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 539,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 568.65,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 540,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 1729.34,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 541,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 1729.34,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 542,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 568.65,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 543,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 1729.34,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 544,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 1729.34,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 545,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 1607.92,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 546,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 547,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 548,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 549,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 550,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 551,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 552,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 553,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 554,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 555,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 556,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 557,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 558,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 559,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 560,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,BCBS,BLUE CROSS BLUE SHIELD, 2404.64,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 561,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,BCBS,BLUE CROSS BLUE SHIELD, 2404.64,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 562,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 563,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 564,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 565,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1146.65,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 566,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1146.65,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 567,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 568,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 569,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,BCBS,BLUE CROSS BLUE SHIELD, 1626.60,,OUTPCT LIMIT, 1055.55,OTHER, 508.57, 1875.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 570,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 571,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 2805.21,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 572,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 2805.21,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 573,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 2805.21,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 574,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 575,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 576,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 577,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 578,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 579,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 580,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 581,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 582,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 583,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 584,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 585,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 586,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 587,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 588,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 589,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 590,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 591,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 592,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 593,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 594,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 595,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 596,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 597,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 598,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 599,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 600,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 601,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 602,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 603,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 604,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 605,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 606,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 607,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 608,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 609,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 2201.71,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 610,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 2201.71,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 611,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 612,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 613,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 614,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 615,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 616,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 617,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,BCBS,BLUE CROSS BLUE SHIELD, 306.24,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 618,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,BCBS,BLUE CROSS BLUE SHIELD, 306.24,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 619,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,BCBS,BLUE CROSS BLUE SHIELD, 306.24,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 620,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 621,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 622,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 623,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,BCBS,BLUE CROSS BLUE SHIELD, 295.77,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 624,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,BCBS,BLUE CROSS BLUE SHIELD, 295.77,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 625,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,BCBS,BLUE CROSS BLUE SHIELD, 295.77,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 626,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,BCBS,BLUE CROSS BLUE SHIELD, 295.77,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 627,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,BCBS,BLUE CROSS BLUE SHIELD, 295.77,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 628,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 629,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 630,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 631,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 632,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,BCBS,BLUE CROSS BLUE SHIELD, 386.90,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 633,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,BCBS,BLUE CROSS BLUE SHIELD, 307.67,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 634,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 635,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 636,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,BCBS,BLUE CROSS BLUE SHIELD, 316.66,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 637,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,BCBS,BLUE CROSS BLUE SHIELD, 316.66,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 638,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,BCBS,BLUE CROSS BLUE SHIELD, 325.80,,OUTPCT LIMIT, 208.23,OTHER, 88.46, 375.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 639,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 640,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 641,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 642,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,BCBS,BLUE CROSS BLUE SHIELD, 331.02,,OUTPCT LIMIT, 210.73,OTHER, 86.34, 381.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 643,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,BCBS,BLUE CROSS BLUE SHIELD, 320.59,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 644,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,BCBS,BLUE CROSS BLUE SHIELD, 320.59,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 645,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 646,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 647,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 648,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 411.26,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 649,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,BCBS,BLUE CROSS BLUE SHIELD, 420.39,,OUTPCT LIMIT, 274.41,OTHER, 138.19, 484.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 650,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 411.26,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 651,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 652,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 653,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 654,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 642.60,,OUTPCT LIMIT, 402.07,OTHER, 138.19, 740.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 655,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 630.91,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 656,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 630.91,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 657,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 658,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 659,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 660,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,BCBS,BLUE CROSS BLUE SHIELD, 231.18,,OUTPCT LIMIT, 153.37,OTHER, 86.34, 266.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 661,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 662,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 387.33,,OUTPCT LIMIT, 243.07,OTHER, 86.34, 446.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 663,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,BCBS,BLUE CROSS BLUE SHIELD, 378.19,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 664,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,BCBS,BLUE CROSS BLUE SHIELD, 378.19,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 665,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 666,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 667,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 668,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.10,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 669,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.10,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 670,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 146.20,,OUTPCT LIMIT, 116.89,OTHER, 73.96, 168.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 671,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 672,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 673,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 674,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,BCBS,BLUE CROSS BLUE SHIELD, 323.84,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 675,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,BCBS,BLUE CROSS BLUE SHIELD, 323.84,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 676,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 334.90,,OUTPCT LIMIT, 225.30,OTHER, 138.19, 386.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 677,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 678,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 679,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 680,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 366.35,,OUTPCT LIMIT, 243.37,OTHER, 138.19, 422.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 681,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,BCBS,BLUE CROSS BLUE SHIELD, 354.86,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 682,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,BCBS,BLUE CROSS BLUE SHIELD, 354.86,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 683,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 684,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 685,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 686,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,BCBS,BLUE CROSS BLUE SHIELD, 288.97,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 687,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,BCBS,BLUE CROSS BLUE SHIELD, 288.97,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 688,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 689,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 690,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,BCBS,BLUE CROSS BLUE SHIELD, 399.72,,OUTPCT LIMIT, 250.19,OTHER, 86.34, 460.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 691,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,BCBS,BLUE CROSS BLUE SHIELD, 390.41,,OUTPCT LIMIT, 244.84,OTHER, 86.34, 450.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 692,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,BCBS,BLUE CROSS BLUE SHIELD, 390.58,,OUTPCT LIMIT, 244.94,OTHER, 86.34, 450.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 693,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 694,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 695,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 696,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 198.05,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 697,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 198.05,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 698,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 198.05,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 699,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 700,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 701,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 702,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 703,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 704,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 705,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 706,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 707,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 708,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 709,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 710,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 179.26,OTHER, 86.34, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 711,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 712,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 713,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 714,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 715,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 716,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 717,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 718,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 719,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 720,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 721,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 722,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 723,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 724,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 725,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 726,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 727,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1959.25,,OUTPCT LIMIT, 1193.14,OTHER, 283.82, 2258.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 728,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 729,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 730,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 731,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 732,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 733,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 734,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 735,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 736,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 737,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 738,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 739,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 740,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 741,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 742,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 743,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 744,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 745,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 746,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 747,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 748,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 749,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 750,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 751,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 752,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2318.80,,OUTPCT LIMIT, 1435.02,OTHER, 432.18, 2673.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 753,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,BCBS,BLUE CROSS BLUE SHIELD, 2307.27,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 754,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,BCBS,BLUE CROSS BLUE SHIELD, 2307.27,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 755,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 756,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 757,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 758,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1146.65,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 759,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1146.65,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 760,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1146.65,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 761,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 762,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 763,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 764,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1180.65,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 765,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1180.65,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 766,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 767,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 768,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,BCBS,BLUE CROSS BLUE SHIELD, 2515.10,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 769,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,BCBS,BLUE CROSS BLUE SHIELD, 2515.10,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 770,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,BCBS,BLUE CROSS BLUE SHIELD, 2515.10,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 771,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,BCBS,BLUE CROSS BLUE SHIELD, 2515.10,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 772,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,BCBS,BLUE CROSS BLUE SHIELD, 2515.10,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 773,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,BCBS,BLUE CROSS BLUE SHIELD, 2515.10,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 774,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 775,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 776,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 777,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 778,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 779,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 780,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,BCBS,BLUE CROSS BLUE SHIELD, 3077.32,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 781,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,BCBS,BLUE CROSS BLUE SHIELD, 3077.32,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 782,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 783,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 784,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,BCBS,BLUE CROSS BLUE SHIELD, 2680.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 785,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,BCBS,BLUE CROSS BLUE SHIELD, 2680.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 786,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,BCBS,BLUE CROSS BLUE SHIELD, 2680.68,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 787,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,BCBS,BLUE CROSS BLUE SHIELD, 2680.68,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 788,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,BCBS,BLUE CROSS BLUE SHIELD, 2680.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 789,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,BCBS,BLUE CROSS BLUE SHIELD, 2680.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 790,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,BCBS,BLUE CROSS BLUE SHIELD, 2680.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 791,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,BCBS,BLUE CROSS BLUE SHIELD, 2680.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 792,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,BCBS,BLUE CROSS BLUE SHIELD, 2680.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 793,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,BCBS,BLUE CROSS BLUE SHIELD, 2680.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 794,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 795,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 796,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 797,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 798,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 799,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 800,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 801,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 802,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 803,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 804,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,BCBS,BLUE CROSS BLUE SHIELD, 3912.47,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 805,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,BCBS,BLUE CROSS BLUE SHIELD, 3912.47,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 806,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,BCBS,BLUE CROSS BLUE SHIELD, 3912.47,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 807,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,BCBS,BLUE CROSS BLUE SHIELD, 3912.47,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 808,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,BCBS,BLUE CROSS BLUE SHIELD, 3912.47,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 809,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 810,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 811,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 812,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 813,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 814,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1700.00,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 815,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1955.00,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 816,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1955.00,,OUTPCT LIMIT, 1474.10,OTHER, 989.00, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 817,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1555.50,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 818,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1555.50,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 819,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 820,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 821,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 822,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 823,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 824,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 141.10,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 825,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 141.10,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 826,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 827,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 828,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.10,,OUTPCT LIMIT, 83.13,OTHER, 36.98, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 829,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 105.42,OTHER, 37.54, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 830,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,BCBS,BLUE CROSS BLUE SHIELD, 503.98,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 831,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,BCBS,BLUE CROSS BLUE SHIELD, 503.98,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 832,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 833,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 834,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,BCBS,BLUE CROSS BLUE SHIELD, 2225.38,,OUTPCT LIMIT, 1346.03,OTHER, 283.82, 2565.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 835,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 836,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,BCBS,BLUE CROSS BLUE SHIELD, 2508.88,,OUTPCT LIMIT, 1544.22,OTHER, 432.18, 2892.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 837,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 838,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,BCBS,BLUE CROSS BLUE SHIELD, 2833.24,,OUTPCT LIMIT, 1743.20,OTHER, 485.27, 3266.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 839,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 840,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,BCBS,BLUE CROSS BLUE SHIELD, 5083.03,,OUTPCT LIMIT, 3113.75,OTHER, 813.20, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 841,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 301.75,,OUTPCT LIMIT, 473.04,OTHER, 156.77, 813.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 842,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,BCBS,BLUE CROSS BLUE SHIELD, 2829.50,,OUTPCT LIMIT, 1743.46,OTHER, 495.38, 3262.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 843,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 844,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,BCBS,BLUE CROSS BLUE SHIELD, 4427.83,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 845,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,BCBS,BLUE CROSS BLUE SHIELD, 4427.83,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 846,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 847,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 848,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,BCBS,BLUE CROSS BLUE SHIELD, 5083.03,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 849,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,BCBS,BLUE CROSS BLUE SHIELD, 5083.03,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 850,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 851,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 852,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,BCBS,BLUE CROSS BLUE SHIELD, 5695.18,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 853,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,BCBS,BLUE CROSS BLUE SHIELD, 5695.18,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 854,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,BCBS,BLUE CROSS BLUE SHIELD, 5695.18,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 855,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 856,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 857,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 858,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 2730.41,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 859,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 2730.41,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 860,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 861,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 862,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,BCBS,BLUE CROSS BLUE SHIELD, 2874.86,,OUTPCT LIMIT, 1837.06,OTHER, 779.04, 3314.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 863,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 864,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2125.00,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 865,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 3440.80,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 866,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 867,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 868,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 869,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 593.30,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 870,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 593.30,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 871,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 593.30,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 872,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 873,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 874,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,BCBS,BLUE CROSS BLUE SHIELD, 933.75,,OUTPCT LIMIT, 704.06,OTHER, 472.37, 1076.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 875,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 68.02,OTHER, 37.54, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 876,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 328.44,,OUTPCT LIMIT, 248.14,OTHER, 166.15, 378.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 877,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 230.64,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 878,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,BCBS,BLUE CROSS BLUE SHIELD, 644.79,,OUTPCT LIMIT, 429.88,OTHER, 249.71, 743.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 879,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 132.91,OTHER, 37.54, 249.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 880,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,BCBS,BLUE CROSS BLUE SHIELD, 2398.00,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 881,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,BCBS,BLUE CROSS BLUE SHIELD, 2398.00,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 882,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 883,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 884,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 297.50,,OUTPCT LIMIT, 224.32,OTHER, 150.50, 343.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 885,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 886,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,BCBS,BLUE CROSS BLUE SHIELD, 612.42,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 887,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,BCBS,BLUE CROSS BLUE SHIELD, 612.42,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 888,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,BCBS,BLUE CROSS BLUE SHIELD, 612.42,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 889,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 890,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 891,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 892,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,BCBS,BLUE CROSS BLUE SHIELD, 461.19,,OUTPCT LIMIT, 286.59,OTHER, 90.89, 531.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 893,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 894,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,BCBS,BLUE CROSS BLUE SHIELD, 434.63,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 895,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,BCBS,BLUE CROSS BLUE SHIELD, 434.63,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 896,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,BCBS,BLUE CROSS BLUE SHIELD, 434.63,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 897,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 446.25,,OUTPCT LIMIT, 288.12,OTHER, 133.37, 514.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 898,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 899,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 900,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 901,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 902,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,BCBS,BLUE CROSS BLUE SHIELD, 817.74,,OUTPCT LIMIT, 503.49,OTHER, 141.55, 942.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 903,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 904,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 746.81,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 905,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 746.81,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 906,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 746.81,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 907,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 746.81,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 908,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 746.81,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 909,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 910,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 911,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 912,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 913,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 914,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 746.81,,OUTPCT LIMIT, 468.07,OTHER, 163.97, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 915,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 200.02,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 916,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 673.54,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 917,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 673.54,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 918,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 673.54,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 919,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 673.54,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 920,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 662.86,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 921,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 922,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 923,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 924,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 925,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 926,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 662.86,,OUTPCT LIMIT, 414.50,OTHER, 141.55, 764.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 927,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 928,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 318.75,,OUTPCT LIMIT, 214.87,OTHER, 133.37, 367.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 929,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 163.37,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 930,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,BCBS,BLUE CROSS BLUE SHIELD, 652.81,,OUTPCT LIMIT, 408.73,OTHER, 141.55, 752.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 931,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 932,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,BCBS,BLUE CROSS BLUE SHIELD, 824.82,,OUTPCT LIMIT, 507.55,OTHER, 141.55, 950.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 933,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 934,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1312.40,,OUTPCT LIMIT, 775.60,OTHER, 90.89, 1513.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 935,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 936,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 450.50,,OUTPCT LIMIT, 290.56,OTHER, 133.37, 519.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 937,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 938,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,BCBS,BLUE CROSS BLUE SHIELD, 672.03,,OUTPCT LIMIT, 419.77,OTHER, 141.55, 774.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 939,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 940,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,BCBS,BLUE CROSS BLUE SHIELD, 762.21,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 941,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,BCBS,BLUE CROSS BLUE SHIELD, 762.21,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 942,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,BCBS,BLUE CROSS BLUE SHIELD, 762.21,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 943,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 944,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 945,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 946,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 531.89,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 947,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,BCBS,BLUE CROSS BLUE SHIELD, 514.18,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 948,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 949,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 950,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,BCBS,BLUE CROSS BLUE SHIELD, 652.36,,OUTPCT LIMIT, 408.48,OTHER, 141.55, 752.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 951,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 952,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1360.00,,OUTPCT LIMIT, 813.95,OTHER, 137.10, 1568.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 953,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,BCBS,BLUE CROSS BLUE SHIELD, 859.89,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 954,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,BCBS,BLUE CROSS BLUE SHIELD, 859.89,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 955,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 956,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 957,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 958,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,BCBS,BLUE CROSS BLUE SHIELD, 305.12,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 959,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 467.50,,OUTPCT LIMIT, 300.33,OTHER, 133.37, 539.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 960,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,BCBS,BLUE CROSS BLUE SHIELD, 305.12,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 961,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,BCBS,BLUE CROSS BLUE SHIELD, 305.12,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 962,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,BCBS,BLUE CROSS BLUE SHIELD, 305.12,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 963,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,BCBS,BLUE CROSS BLUE SHIELD, 305.12,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 964,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,BCBS,BLUE CROSS BLUE SHIELD, 305.12,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 965,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,BCBS,BLUE CROSS BLUE SHIELD, 305.12,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 966,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,BCBS,BLUE CROSS BLUE SHIELD, 305.12,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 967,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 968,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 969,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 970,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 971,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 972,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 973,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 974,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 975,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 976,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,BCBS,BLUE CROSS BLUE SHIELD, 565.16,,OUTPCT LIMIT, 426.14,OTHER, 285.90, 651.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 977,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 978,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,BCBS,BLUE CROSS BLUE SHIELD, 360.90,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 979,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,BCBS,BLUE CROSS BLUE SHIELD, 360.90,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 980,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,BCBS,BLUE CROSS BLUE SHIELD, 360.90,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 981,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 303.45,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 982,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 983,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 303.45,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 984,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 303.45,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 985,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 247.35,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 986,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 247.35,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 987,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 120.70,,OUTPCT LIMIT, 91.01,OTHER, 61.06, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 988,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 157.25,,OUTPCT LIMIT, 78.82,OTHER, 21.15, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 989,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 247.35,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 990,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 247.35,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 991,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 247.35,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 992,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 247.35,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 993,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 994,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 995,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 996,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 997,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 416.50,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 998,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 347.65,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 999,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 416.50,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1000,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1001,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1002,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 247.35,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1003,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 247.35,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1004,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 247.35,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1005,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 247.35,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1006,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 510.00,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1007,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 352.75,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1008,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 352.75,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1009,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1010,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1011,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1012,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1013,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1014,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1015,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1016,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 145.35,,OUTPCT LIMIT, 116.40,OTHER, 73.53, 167.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1017,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 35.70,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1018,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 624.61,,OUTPCT LIMIT, 414.07,OTHER, 232.03, 720.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1019,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 166.60,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1020,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 298.35,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1021,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 35.70,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1022,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 35.70,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1023,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 251.60,,OUTPCT LIMIT, 154.63,OTHER, 42.36, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1024,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 298.35,,OUTPCT LIMIT, 204.30,OTHER, 138.19, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1025,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 35.70,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1026,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 1085.31,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1027,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 1085.31,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1028,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1029,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1030,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,BCBS,BLUE CROSS BLUE SHIELD, 843.68,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1031,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,BCBS,BLUE CROSS BLUE SHIELD, 843.68,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1032,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1033,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1034,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,BCBS,BLUE CROSS BLUE SHIELD, 1186.52,,OUTPCT LIMIT, 757.92,OTHER, 320.35, 1367.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1035,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 230.15,OTHER, 99.36, 320.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1036,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,BCBS,BLUE CROSS BLUE SHIELD, 1432.58,,OUTPCT LIMIT, 899.81,OTHER, 322.62, 1651.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1037,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 230.96,OTHER, 99.36, 322.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1038,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1674.50,,OUTPCT LIMIT, 1092.65,OTHER, 548.80, 1930.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1039,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 311.74,OTHER, 99.36, 548.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1040,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 1328.66,,OUTPCT LIMIT, 864.03,OTHER, 423.08, 1531.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1041,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1042,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 425.00,,OUTPCT LIMIT, 344.89,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1043,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1044,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1275.00,,OUTPCT LIMIT, 830.31,OTHER, 410.92, 1470.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1045,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1046,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1751.00,,OUTPCT LIMIT, 1103.77,OTHER, 410.92, 2018.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1047,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1048,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1785.00,,OUTPCT LIMIT, 1111.16,OTHER, 359.95, 2058.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1049,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1050,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 937.13,,OUTPCT LIMIT, 624.07,OTHER, 359.95, 1080.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1051,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1052,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,BCBS,BLUE CROSS BLUE SHIELD, 1021.13,,OUTPCT LIMIT, 672.34,OTHER, 360.01, 1177.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1053,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1054,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 824.50,,OUTPCT LIMIT, 559.38,OTHER, 360.01, 950.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1055,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1056,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,BCBS,BLUE CROSS BLUE SHIELD, 1988.46,,OUTPCT LIMIT, 1228.06,OTHER, 360.01, 2292.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1057,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1058,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,BCBS,BLUE CROSS BLUE SHIELD, 2103.33,,OUTPCT LIMIT, 1294.05,OTHER, 360.01, 2425.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1059,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1060,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 930.75,,OUTPCT LIMIT, 701.80,OTHER, 470.85, 1073.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1061,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 180.04,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1062,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 1532.98,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1063,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 1532.98,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1064,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1065,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1066,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,BCBS,BLUE CROSS BLUE SHIELD, 3480.14,,OUTPCT LIMIT, 2267.81,OTHER, 1127.76, 4012.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1067,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1068,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,BCBS,BLUE CROSS BLUE SHIELD, 1234.29,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1069,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,BCBS,BLUE CROSS BLUE SHIELD, 1234.29,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1070,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1071,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1072,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 989.19,,OUTPCT LIMIT, 635.79,OTHER, 283.54, 1140.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1073,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 217.00,OTHER, 99.36, 283.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1074,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 1588.51,,OUTPCT LIMIT, 984.09,OTHER, 300.36, 1831.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1075,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 223.01,OTHER, 99.36, 300.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1076,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,BCBS,BLUE CROSS BLUE SHIELD, 1644.17,,OUTPCT LIMIT, 1050.06,OTHER, 443.12, 1895.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1077,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 274.00,OTHER, 99.36, 443.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1078,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 884.00,,OUTPCT LIMIT, 684.67,OTHER, 447.20, 1019.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1079,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.25,,OUTPCT LIMIT, 380.97,OTHER, 99.36, 742.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1080,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 4049.40,,OUTPCT LIMIT, 2685.69,OTHER, 1509.32, 4668.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1081,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 340.00,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1082,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 4193.90,,OUTPCT LIMIT, 2768.70,OTHER, 1509.32, 4835.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1083,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 340.00,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1084,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,BCBS,BLUE CROSS BLUE SHIELD, 51.50,,OUTPCT LIMIT, 34.30,OTHER, 19.78, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1085,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,BCBS,BLUE CROSS BLUE SHIELD, 51.50,,OUTPCT LIMIT, 32.49,OTHER, 12.18, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1086,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 528.70,,OUTPCT LIMIT, 398.65,OTHER, 267.46, 609.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1087,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,BCBS,BLUE CROSS BLUE SHIELD, 118.87,,OUTPCT LIMIT, 70.69,OTHER, 10.09, 137.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1088,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 206.34,,OUTPCT LIMIT, 122.16,OTHER, 15.20, 237.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1089,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,BCBS,BLUE CROSS BLUE SHIELD, 161.90,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1090,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,BCBS,BLUE CROSS BLUE SHIELD, 161.90,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1091,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 140.25,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1092,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 140.25,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1093,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,BCBS,BLUE CROSS BLUE SHIELD, 242.86,,OUTPCT LIMIT, 155.85,OTHER, 68.59, 280.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1094,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,BCBS,BLUE CROSS BLUE SHIELD, 132.61,,OUTPCT LIMIT, 78.98,OTHER, 11.76, 152.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1095,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 111.35,,OUTPCT LIMIT, 69.30,OTHER, 22.37, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1096,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 379.95,,OUTPCT LIMIT, 229.30,OTHER, 46.28, 438.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1097,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,BCBS,BLUE CROSS BLUE SHIELD, 149.82,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1098,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 142.46,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1099,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,BCBS,BLUE CROSS BLUE SHIELD, 85.01,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1100,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,BCBS,BLUE CROSS BLUE SHIELD, 85.01,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1101,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 131.47,,OUTPCT LIMIT, 80.17,OTHER, 19.50, 151.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1102,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,BCBS,BLUE CROSS BLUE SHIELD, 82.13,,OUTPCT LIMIT, 54.61,OTHER, 31.20, 94.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1103,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,BCBS,BLUE CROSS BLUE SHIELD, 131.39,,OUTPCT LIMIT, 80.03,OTHER, 19.08, 151.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1104,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 129.91,,OUTPCT LIMIT, 79.17,OTHER, 19.08, 149.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1105,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,BCBS,BLUE CROSS BLUE SHIELD, 107.37,,OUTPCT LIMIT, 63.95,OTHER, 9.52, 123.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1106,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 39.95,,OUTPCT LIMIT, 28.28,OTHER, 20.21, 46.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1107,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,BCBS,BLUE CROSS BLUE SHIELD, 137.77,,OUTPCT LIMIT, 83.69,OTHER, 19.08, 158.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1108,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 83.94,,OUTPCT LIMIT, 53.47,OTHER, 22.03, 96.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1109,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,BCBS,BLUE CROSS BLUE SHIELD, 131.02,,OUTPCT LIMIT, 79.81,OTHER, 19.08, 151.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1110,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,BCBS,BLUE CROSS BLUE SHIELD, 69.51,,OUTPCT LIMIT, 44.64,OTHER, 19.78, 80.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1111,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,BCBS,BLUE CROSS BLUE SHIELD, 245.79,,OUTPCT LIMIT, 145.91,OTHER, 19.78, 283.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1112,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,BCBS,BLUE CROSS BLUE SHIELD, 104.30,,OUTPCT LIMIT, 64.76,OTHER, 20.36, 120.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1113,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,BCBS,BLUE CROSS BLUE SHIELD, 204.10,,OUTPCT LIMIT, 121.34,OTHER, 17.16, 235.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1114,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,BCBS,BLUE CROSS BLUE SHIELD, 139.45,,OUTPCT LIMIT, 84.76,OTHER, 19.50, 160.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1115,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,BCBS,BLUE CROSS BLUE SHIELD, 220.97,,OUTPCT LIMIT, 134.69,OTHER, 32.53, 254.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1116,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,BCBS,BLUE CROSS BLUE SHIELD, 147.12,,OUTPCT LIMIT, 90.91,OTHER, 26.84, 169.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1117,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,BCBS,BLUE CROSS BLUE SHIELD, 161.79,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1118,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 21.25,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1119,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 34.00,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1120,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 34.00,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1121,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,BCBS,BLUE CROSS BLUE SHIELD, 222.60,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1122,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 250.75,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1123,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 143.65,,OUTPCT LIMIT, 108.31,OTHER, 72.67, 165.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1124,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 127.50,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1125,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 64.60,,OUTPCT LIMIT, 48.71,OTHER, 32.68, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1126,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,BCBS,BLUE CROSS BLUE SHIELD, 238.65,,OUTPCT LIMIT, 179.95,OTHER, 120.73, 275.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1127,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,BCBS,BLUE CROSS BLUE SHIELD, 152.02,,OUTPCT LIMIT, 114.63,OTHER, 76.91, 175.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1128,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 34.71,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1129,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 63.75,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1130,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 34.71,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1131,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 34.71,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1132,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 119.85,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1133,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,BCBS,BLUE CROSS BLUE SHIELD, 90.01,,OUTPCT LIMIT, 67.87,OTHER, 45.53, 103.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1134,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 135.15,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1135,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 135.15,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1136,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 135.15,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1137,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 114.75,,OUTPCT LIMIT, 86.52,OTHER, 58.05, 132.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1138,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.10,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1139,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 247.35,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1140,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,BCBS,BLUE CROSS BLUE SHIELD, 58.83,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1141,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,BCBS,BLUE CROSS BLUE SHIELD, 58.83,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1142,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,BCBS,BLUE CROSS BLUE SHIELD, 58.83,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1143,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,BCBS,BLUE CROSS BLUE SHIELD, 35.10,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1144,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,BCBS,BLUE CROSS BLUE SHIELD, 35.10,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1145,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,BCBS,BLUE CROSS BLUE SHIELD, 35.10,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1146,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 11.05,,OUTPCT LIMIT, 7.12,OTHER, 3.24, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1147,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 12.75,,OUTPCT LIMIT, 8.07,OTHER, 3.12, 14.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1148,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,BCBS,BLUE CROSS BLUE SHIELD, 53.81,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1149,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,BCBS,BLUE CROSS BLUE SHIELD, 53.81,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1150,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 126.65,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1151,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 126.65,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1152,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,BCBS,BLUE CROSS BLUE SHIELD, 209.64,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1153,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,BCBS,BLUE CROSS BLUE SHIELD, 209.64,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1154,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 418.20,,OUTPCT LIMIT, 262.66,OTHER, 94.12, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1155,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,BCBS,BLUE CROSS BLUE SHIELD, 692.02,,OUTPCT LIMIT, 428.98,OTHER, 131.99, 797.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1156,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,BCBS,BLUE CROSS BLUE SHIELD, 171.99,,OUTPCT LIMIT, 129.68,OTHER, 87.01, 198.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1157,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 324.70,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1158,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 324.70,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1159,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.82,,OUTPCT LIMIT, 53.15,OTHER, 6.50, 103.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1160,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,BCBS,BLUE CROSS BLUE SHIELD, 62.85,,OUTPCT LIMIT, 38.90,OTHER, 11.76, 72.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1161,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,BCBS,BLUE CROSS BLUE SHIELD, 232.54,,OUTPCT LIMIT, 146.83,OTHER, 55.61, 268.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1162,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 32.09,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1163,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 32.09,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1164,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 45.69,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1165,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 45.69,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1166,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 102.00,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1167,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 102.00,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1168,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,BCBS,BLUE CROSS BLUE SHIELD, 82.76,,OUTPCT LIMIT, 50.88,OTHER, 13.98, 95.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1169,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,BCBS,BLUE CROSS BLUE SHIELD, 115.68,,OUTPCT LIMIT, 71.06,OTHER, 19.36, 133.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1170,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 182.61,,OUTPCT LIMIT, 109.86,OTHER, 20.82, 210.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1171,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,BCBS,BLUE CROSS BLUE SHIELD, 129.53,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1172,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,BCBS,BLUE CROSS BLUE SHIELD, 129.53,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1173,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 101.15,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1174,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 101.15,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1175,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,BCBS,BLUE CROSS BLUE SHIELD, 84.54,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1176,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,BCBS,BLUE CROSS BLUE SHIELD, 84.54,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1177,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 157.25,,OUTPCT LIMIT, 100.38,OTHER, 42.16, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1178,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,BCBS,BLUE CROSS BLUE SHIELD, 193.03,,OUTPCT LIMIT, 121.92,OTHER, 46.34, 222.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1179,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 74.80,,OUTPCT LIMIT, 50.20,OTHER, 30.37, 86.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1180,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.15,,OUTPCT LIMIT, 116.31,OTHER, 27.31, 220.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1181,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 80.75,,OUTPCT LIMIT, 49.78,OTHER, 14.24, 93.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1182,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,BCBS,BLUE CROSS BLUE SHIELD, 100.78,,OUTPCT LIMIT, 63.44,OTHER, 23.30, 116.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1183,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,BCBS,BLUE CROSS BLUE SHIELD, 60.30,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1184,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,BCBS,BLUE CROSS BLUE SHIELD, 60.30,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1185,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 54.57,,OUTPCT LIMIT, 33.07,OTHER, 7.22, 62.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1186,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 31.03,,OUTPCT LIMIT, 19.33,OTHER, 6.31, 35.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1187,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,BCBS,BLUE CROSS BLUE SHIELD, 55.39,,OUTPCT LIMIT, 33.34,OTHER, 6.38, 63.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1188,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 56.73,OTHER, 22.92, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1189,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,BCBS,BLUE CROSS BLUE SHIELD, 198.42,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1190,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 211.65,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1191,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,BCBS,BLUE CROSS BLUE SHIELD, 198.42,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1192,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,BCBS,BLUE CROSS BLUE SHIELD, 199.26,,OUTPCT LIMIT, 123.66,OTHER, 38.58, 229.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1193,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.24,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1194,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.24,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1195,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.24,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1196,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,BCBS,BLUE CROSS BLUE SHIELD, 112.36,,OUTPCT LIMIT, 69.24,OTHER, 19.70, 129.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1197,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,BCBS,BLUE CROSS BLUE SHIELD, 83.38,,OUTPCT LIMIT, 49.97,OTHER, 8.69, 96.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1198,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 69.70,,OUTPCT LIMIT, 44.47,OTHER, 18.58, 80.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1199,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 106.04,,OUTPCT LIMIT, 65.14,OTHER, 17.74, 122.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1200,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,BCBS,BLUE CROSS BLUE SHIELD, 140.56,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1201,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,BCBS,BLUE CROSS BLUE SHIELD, 140.56,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1202,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 92.65,,OUTPCT LIMIT, 59.01,OTHER, 24.29, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1203,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,BCBS,BLUE CROSS BLUE SHIELD, 206.64,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1204,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,BCBS,BLUE CROSS BLUE SHIELD, 208.61,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1205,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,BCBS,BLUE CROSS BLUE SHIELD, 91.86,,OUTPCT LIMIT, 56.46,OTHER, 15.47, 105.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1206,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 20.40,,OUTPCT LIMIT, 13.69,OTHER, 8.28, 23.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1207,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,BCBS,BLUE CROSS BLUE SHIELD, 120.90,,OUTPCT LIMIT, 73.71,OTHER, 17.87, 139.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1208,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,BCBS,BLUE CROSS BLUE SHIELD, 142.74,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1209,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,BCBS,BLUE CROSS BLUE SHIELD, 142.74,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1210,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,BCBS,BLUE CROSS BLUE SHIELD, 105.70,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1211,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,BCBS,BLUE CROSS BLUE SHIELD, 105.70,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1212,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,BCBS,BLUE CROSS BLUE SHIELD, 316.68,,OUTPCT LIMIT, 190.19,OTHER, 34.69, 365.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1213,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,BCBS,BLUE CROSS BLUE SHIELD, 358.16,,OUTPCT LIMIT, 214.01,OTHER, 34.69, 412.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1214,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 78.78,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1215,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 78.78,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1216,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 64.60,,OUTPCT LIMIT, 41.70,OTHER, 19.28, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1217,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 97.07,,OUTPCT LIMIT, 59.73,OTHER, 16.63, 111.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1218,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,BCBS,BLUE CROSS BLUE SHIELD, 51.99,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1219,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,BCBS,BLUE CROSS BLUE SHIELD, 51.99,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1220,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,BCBS,BLUE CROSS BLUE SHIELD, 51.99,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1221,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,BCBS,BLUE CROSS BLUE SHIELD, 64.99,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1222,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,BCBS,BLUE CROSS BLUE SHIELD, 64.99,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1223,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,BCBS,BLUE CROSS BLUE SHIELD, 157.05,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1224,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,BCBS,BLUE CROSS BLUE SHIELD, 157.05,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1225,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 71.40,,OUTPCT LIMIT, 45.06,OTHER, 16.97, 82.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1226,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,BCBS,BLUE CROSS BLUE SHIELD, 128.80,,OUTPCT LIMIT, 76.21,OTHER, 9.31, 148.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1227,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,BCBS,BLUE CROSS BLUE SHIELD, 116.73,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1228,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,BCBS,BLUE CROSS BLUE SHIELD, 116.73,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1229,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,BCBS,BLUE CROSS BLUE SHIELD, 120.13,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1230,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,BCBS,BLUE CROSS BLUE SHIELD, 120.13,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1231,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 206.72,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1232,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 206.72,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1233,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,BCBS,BLUE CROSS BLUE SHIELD, 152.18,,OUTPCT LIMIT, 93.87,OTHER, 27.06, 175.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1234,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,BCBS,BLUE CROSS BLUE SHIELD, 219.16,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1235,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,BCBS,BLUE CROSS BLUE SHIELD, 219.16,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1236,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 126.65,,OUTPCT LIMIT, 83.83,OTHER, 46.51, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1237,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 113.90,,OUTPCT LIMIT, 73.72,OTHER, 34.82, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1238,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 116.45,,OUTPCT LIMIT, 75.45,OTHER, 35.93, 134.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1239,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 197.84,,OUTPCT LIMIT, 121.64,OTHER, 33.53, 228.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1240,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,BCBS,BLUE CROSS BLUE SHIELD, 117.35,,OUTPCT LIMIT, 69.17,OTHER, 7.34, 135.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1241,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,BCBS,BLUE CROSS BLUE SHIELD, 206.98,,OUTPCT LIMIT, 124.67,OTHER, 24.19, 238.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1242,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 124.95,,OUTPCT LIMIT, 76.46,OTHER, 19.63, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1243,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,BCBS,BLUE CROSS BLUE SHIELD, 115.65,,OUTPCT LIMIT, 71.48,OTHER, 21.17, 133.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1244,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,BCBS,BLUE CROSS BLUE SHIELD, 360.20,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1245,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,BCBS,BLUE CROSS BLUE SHIELD, 131.76,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1246,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.90,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1247,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.90,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1248,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.90,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1249,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,BCBS,BLUE CROSS BLUE SHIELD, 103.25,,OUTPCT LIMIT, 64.96,OTHER, 23.70, 119.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1250,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.10,,OUTPCT LIMIT, 34.98,OTHER, 11.54, 64.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1251,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,BCBS,BLUE CROSS BLUE SHIELD, 338.71,,OUTPCT LIMIT, 203.52,OTHER, 37.54, 390.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1252,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 96.90,,OUTPCT LIMIT, 61.71,OTHER, 25.39, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1253,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 42.29,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1254,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 42.29,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1255,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 42.29,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1256,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,BCBS,BLUE CROSS BLUE SHIELD, 46.95,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1257,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,BCBS,BLUE CROSS BLUE SHIELD, 46.95,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1258,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,BCBS,BLUE CROSS BLUE SHIELD, 46.95,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1259,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 22.27,,OUTPCT LIMIT, 14.14,OTHER, 5.66, 25.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1260,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 109.37,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1261,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 109.37,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1262,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,BCBS,BLUE CROSS BLUE SHIELD, 95.02,,OUTPCT LIMIT, 57.91,OTHER, 13.97, 109.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1263,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 61.06,,OUTPCT LIMIT, 37.55,OTHER, 10.37, 70.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1264,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 153.81,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1265,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 153.81,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1266,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,BCBS,BLUE CROSS BLUE SHIELD, 153.48,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1267,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,BCBS,BLUE CROSS BLUE SHIELD, 153.48,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1268,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,BCBS,BLUE CROSS BLUE SHIELD, 109.20,,OUTPCT LIMIT, 67.05,OTHER, 18.12, 125.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1269,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 117.30,,OUTPCT LIMIT, 74.92,OTHER, 31.62, 135.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1270,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,BCBS,BLUE CROSS BLUE SHIELD, 78.29,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1271,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,BCBS,BLUE CROSS BLUE SHIELD, 78.29,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1272,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,BCBS,BLUE CROSS BLUE SHIELD, 78.29,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1273,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,BCBS,BLUE CROSS BLUE SHIELD, 163.08,,OUTPCT LIMIT, 99.83,OTHER, 25.80, 188.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1274,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 255.85,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1275,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,BCBS,BLUE CROSS BLUE SHIELD, 225.57,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1276,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,BCBS,BLUE CROSS BLUE SHIELD, 225.57,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1277,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,BCBS,BLUE CROSS BLUE SHIELD, 225.57,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1278,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,BCBS,BLUE CROSS BLUE SHIELD, 225.57,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1279,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,BCBS,BLUE CROSS BLUE SHIELD, 225.57,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1280,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,BCBS,BLUE CROSS BLUE SHIELD, 252.12,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1281,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,BCBS,BLUE CROSS BLUE SHIELD, 152.20,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1282,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,BCBS,BLUE CROSS BLUE SHIELD, 234.68,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1283,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 36.55,,OUTPCT LIMIT, 25.93,OTHER, 18.49, 42.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1284,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,BCBS,BLUE CROSS BLUE SHIELD, 113.36,,OUTPCT LIMIT, 69.04,OTHER, 16.46, 130.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1285,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.52,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1286,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.52,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1287,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.52,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1288,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 88.74,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1289,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 88.74,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1290,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 88.74,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1291,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 88.74,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1292,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,BCBS,BLUE CROSS BLUE SHIELD, 115.01,,OUTPCT LIMIT, 70.04,OTHER, 16.66, 132.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1293,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.49,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1294,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,BCBS,BLUE CROSS BLUE SHIELD, 96.83,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1295,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 141.10,,OUTPCT LIMIT, 85.45,OTHER, 18.42, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1296,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 107.95,,OUTPCT LIMIT, 68.77,OTHER, 28.37, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1297,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,BCBS,BLUE CROSS BLUE SHIELD, 88.10,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1298,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,BCBS,BLUE CROSS BLUE SHIELD, 88.10,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1299,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,BCBS,BLUE CROSS BLUE SHIELD, 101.16,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1300,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,BCBS,BLUE CROSS BLUE SHIELD, 101.16,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1301,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,BCBS,BLUE CROSS BLUE SHIELD, 231.81,,OUTPCT LIMIT, 149.05,OTHER, 66.68, 267.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1302,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 55.25,,OUTPCT LIMIT, 43.46,OTHER, 27.95, 63.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1303,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,BCBS,BLUE CROSS BLUE SHIELD, 68.60,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1304,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,BCBS,BLUE CROSS BLUE SHIELD, 68.60,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1305,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 66.74,,OUTPCT LIMIT, 40.64,OTHER, 9.65, 76.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1306,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,BCBS,BLUE CROSS BLUE SHIELD, 340.77,,OUTPCT LIMIT, 204.04,OTHER, 34.72, 392.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1307,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,BCBS,BLUE CROSS BLUE SHIELD, 90.37,,OUTPCT LIMIT, 57.49,OTHER, 23.41, 104.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1308,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,BCBS,BLUE CROSS BLUE SHIELD, 267.64,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1309,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,BCBS,BLUE CROSS BLUE SHIELD, 267.64,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1310,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 141.67,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1311,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 103.29,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1312,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 186.15,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1313,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 186.15,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1314,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,BCBS,BLUE CROSS BLUE SHIELD, 180.48,,OUTPCT LIMIT, 110.95,OTHER, 30.54, 208.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1315,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,BCBS,BLUE CROSS BLUE SHIELD, 90.35,,OUTPCT LIMIT, 54.17,OTHER, 9.52, 104.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1316,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.30,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1317,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.30,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1318,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,BCBS,BLUE CROSS BLUE SHIELD, 141.33,,OUTPCT LIMIT, 86.15,OTHER, 20.81, 162.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1319,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,BCBS,BLUE CROSS BLUE SHIELD, 231.24,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1320,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,BCBS,BLUE CROSS BLUE SHIELD, 231.24,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1321,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 64.60,,OUTPCT LIMIT, 43.75,OTHER, 27.89, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1322,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,BCBS,BLUE CROSS BLUE SHIELD, 313.11,,OUTPCT LIMIT, 186.61,OTHER, 28.27, 361.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1323,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.10,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1324,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 80.41,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1325,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,BCBS,BLUE CROSS BLUE SHIELD, 58.43,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1326,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,BCBS,BLUE CROSS BLUE SHIELD, 58.43,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1327,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,BCBS,BLUE CROSS BLUE SHIELD, 47.41,,OUTPCT LIMIT, 28.87,OTHER, 6.85, 54.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1328,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 21.25,,OUTPCT LIMIT, 13.83,OTHER, 6.82, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1329,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,BCBS,BLUE CROSS BLUE SHIELD, 70.60,,OUTPCT LIMIT, 45.56,OTHER, 21.01, 81.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1330,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,BCBS,BLUE CROSS BLUE SHIELD, 148.95,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1331,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,BCBS,BLUE CROSS BLUE SHIELD, 148.95,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1332,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 162.69,,OUTPCT LIMIT, 102.79,OTHER, 39.19, 187.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1333,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,BCBS,BLUE CROSS BLUE SHIELD, 157.57,,OUTPCT LIMIT, 97.17,OTHER, 27.91, 181.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1334,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,BCBS,BLUE CROSS BLUE SHIELD, 140.51,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1335,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,BCBS,BLUE CROSS BLUE SHIELD, 151.59,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1336,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,BCBS,BLUE CROSS BLUE SHIELD, 151.59,,OUTPCT LIMIT, 93.39,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1337,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,BCBS,BLUE CROSS BLUE SHIELD, 40.73,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1338,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,BCBS,BLUE CROSS BLUE SHIELD, 40.73,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1339,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,BCBS,BLUE CROSS BLUE SHIELD, 98.49,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1340,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,BCBS,BLUE CROSS BLUE SHIELD, 98.49,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1341,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,BCBS,BLUE CROSS BLUE SHIELD, 98.49,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1342,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,BCBS,BLUE CROSS BLUE SHIELD, 69.53,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1343,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,BCBS,BLUE CROSS BLUE SHIELD, 69.53,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1344,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.61,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1345,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,BCBS,BLUE CROSS BLUE SHIELD, 338.38,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1346,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,BCBS,BLUE CROSS BLUE SHIELD, 150.33,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1347,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 129.64,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1348,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,BCBS,BLUE CROSS BLUE SHIELD, 342.01,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1349,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,BCBS,BLUE CROSS BLUE SHIELD, 221.41,,OUTPCT LIMIT, 136.35,OTHER, 38.44, 255.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1350,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,BCBS,BLUE CROSS BLUE SHIELD, 163.00,,OUTPCT LIMIT, 103.27,OTHER, 40.46, 187.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1351,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 120.70,,OUTPCT LIMIT, 76.88,OTHER, 31.67, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1352,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 299.20,,OUTPCT LIMIT, 178.83,OTHER, 29.15, 344.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1353,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 140.96,,OUTPCT LIMIT, 88.43,OTHER, 31.30, 162.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1354,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,BCBS,BLUE CROSS BLUE SHIELD, 49.39,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1355,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,BCBS,BLUE CROSS BLUE SHIELD, 49.39,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1356,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,BCBS,BLUE CROSS BLUE SHIELD, 76.81,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1357,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,BCBS,BLUE CROSS BLUE SHIELD, 76.81,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1358,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,BCBS,BLUE CROSS BLUE SHIELD, 15.77,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1359,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,BCBS,BLUE CROSS BLUE SHIELD, 301.89,,OUTPCT LIMIT, 180.72,OTHER, 30.61, 348.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1360,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,BCBS,BLUE CROSS BLUE SHIELD, 522.51,,OUTPCT LIMIT, 302.95,OTHER, 11.66, 602.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1361,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 127.36,,OUTPCT LIMIT, 81.90,OTHER, 36.67, 146.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1362,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,BCBS,BLUE CROSS BLUE SHIELD, 198.92,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1363,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,BCBS,BLUE CROSS BLUE SHIELD, 198.92,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1364,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,BCBS,BLUE CROSS BLUE SHIELD, 198.92,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1365,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,BCBS,BLUE CROSS BLUE SHIELD, 198.92,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1366,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,BCBS,BLUE CROSS BLUE SHIELD, 138.41,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1367,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,BCBS,BLUE CROSS BLUE SHIELD, 138.41,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1368,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,BCBS,BLUE CROSS BLUE SHIELD, 177.28,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1369,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,BCBS,BLUE CROSS BLUE SHIELD, 177.28,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1370,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,BCBS,BLUE CROSS BLUE SHIELD, 88.63,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1371,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,BCBS,BLUE CROSS BLUE SHIELD, 88.63,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1372,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 126.82,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1373,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 126.82,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1374,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 126.82,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1375,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 81.60,,OUTPCT LIMIT, 51.95,OTHER, 21.29, 94.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1376,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,BCBS,BLUE CROSS BLUE SHIELD, 117.97,,OUTPCT LIMIT, 73.53,OTHER, 24.19, 136.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1377,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 238.00,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1378,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 238.00,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1379,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 78.20,,OUTPCT LIMIT, 49.79,OTHER, 20.42, 90.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1380,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 63.61,,OUTPCT LIMIT, 38.32,OTHER, 7.46, 73.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1381,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,BCBS,BLUE CROSS BLUE SHIELD, 59.48,,OUTPCT LIMIT, 35.99,OTHER, 7.63, 68.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1382,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,BCBS,BLUE CROSS BLUE SHIELD, 94.23,,OUTPCT LIMIT, 58.51,OTHER, 18.37, 108.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1383,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,BCBS,BLUE CROSS BLUE SHIELD, 64.69,,OUTPCT LIMIT, 39.13,OTHER, 8.27, 74.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1384,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,BCBS,BLUE CROSS BLUE SHIELD, 129.76,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1385,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,BCBS,BLUE CROSS BLUE SHIELD, 129.76,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1386,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 127.23,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1387,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 127.23,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1388,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,BCBS,BLUE CROSS BLUE SHIELD, 211.46,,OUTPCT LIMIT, 126.89,OTHER, 22.69, 243.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1389,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 137.02,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1390,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 137.02,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1391,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,BCBS,BLUE CROSS BLUE SHIELD, 65.75,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1392,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,BCBS,BLUE CROSS BLUE SHIELD, 65.75,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1393,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,BCBS,BLUE CROSS BLUE SHIELD, 65.75,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1394,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,BCBS,BLUE CROSS BLUE SHIELD, 36.02,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1395,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,BCBS,BLUE CROSS BLUE SHIELD, 36.02,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1396,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,BCBS,BLUE CROSS BLUE SHIELD, 52.79,,OUTPCT LIMIT, 31.87,OTHER, 6.50, 60.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1397,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 65.03,,OUTPCT LIMIT, 39.10,OTHER, 7.32, 74.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1398,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,BCBS,BLUE CROSS BLUE SHIELD, 125.94,,OUTPCT LIMIT, 76.33,OTHER, 16.72, 145.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1399,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 172.34,,OUTPCT LIMIT, 103.71,OTHER, 19.75, 198.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1400,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,BCBS,BLUE CROSS BLUE SHIELD, 91.87,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1401,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,BCBS,BLUE CROSS BLUE SHIELD, 91.87,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1402,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,BCBS,BLUE CROSS BLUE SHIELD, 91.87,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1403,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,BCBS,BLUE CROSS BLUE SHIELD, 136.60,,OUTPCT LIMIT, 85.61,OTHER, 29.96, 157.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1404,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,BCBS,BLUE CROSS BLUE SHIELD, 159.93,,OUTPCT LIMIT, 97.04,OTHER, 21.67, 184.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1405,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,BCBS,BLUE CROSS BLUE SHIELD, 71.77,,OUTPCT LIMIT, 42.88,OTHER, 6.94, 82.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1406,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.98,,OUTPCT LIMIT, 43.80,OTHER, 5.47, 85.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1407,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,BCBS,BLUE CROSS BLUE SHIELD, 29.66,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1408,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,BCBS,BLUE CROSS BLUE SHIELD, 29.66,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1409,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,BCBS,BLUE CROSS BLUE SHIELD, 35.94,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1410,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,BCBS,BLUE CROSS BLUE SHIELD, 35.94,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1411,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1412,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.02,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1413,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.97,,OUTPCT LIMIT, 44.71,OTHER, 9.31, 85.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1414,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,BCBS,BLUE CROSS BLUE SHIELD, 63.16,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1415,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,BCBS,BLUE CROSS BLUE SHIELD, 63.16,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1416,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 33.15,,OUTPCT LIMIT, 19.92,OTHER, 3.66, 38.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1417,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 54.12,,OUTPCT LIMIT, 32.63,OTHER, 6.46, 62.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1418,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,BCBS,BLUE CROSS BLUE SHIELD, 157.77,,OUTPCT LIMIT, 96.77,OTHER, 25.78, 181.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1419,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,BCBS,BLUE CROSS BLUE SHIELD, 211.39,,OUTPCT LIMIT, 129.31,OTHER, 33.04, 243.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1420,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 220.15,,OUTPCT LIMIT, 130.54,OTHER, 17.06, 253.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1421,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 162.92,,OUTPCT LIMIT, 98.34,OTHER, 19.93, 187.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1422,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 145.78,,OUTPCT LIMIT, 89.00,OTHER, 22.06, 168.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1423,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 164.90,,OUTPCT LIMIT, 98.22,OTHER, 14.66, 190.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1424,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.30,,OUTPCT LIMIT, 54.63,OTHER, 13.99, 102.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1425,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 111.35,,OUTPCT LIMIT, 70.40,OTHER, 27.00, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1426,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,BCBS,BLUE CROSS BLUE SHIELD, 49.52,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1427,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,BCBS,BLUE CROSS BLUE SHIELD, 49.20,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1428,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,BCBS,BLUE CROSS BLUE SHIELD, 49.52,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1429,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 22.10,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1430,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 22.10,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1431,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 22.10,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1432,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 22.10,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1433,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 69.87,,OUTPCT LIMIT, 41.60,OTHER, 6.14, 80.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1434,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 44.20,,OUTPCT LIMIT, 26.32,OTHER, 3.89, 50.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1435,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,BCBS,BLUE CROSS BLUE SHIELD, 59.98,,OUTPCT LIMIT, 36.35,OTHER, 7.93, 69.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1436,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 144.50,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1437,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,BCBS,BLUE CROSS BLUE SHIELD, 63.65,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1438,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 128.79,,OUTPCT LIMIT, 76.67,OTHER, 11.26, 148.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1439,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,BCBS,BLUE CROSS BLUE SHIELD, 1010.10,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1440,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 274.55,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1441,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1442,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1443,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1444,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1445,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1446,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1447,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1448,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1449,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1450,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1451,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1452,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1453,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1454,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1455,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1456,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1457,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1458,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1459,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1460,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1461,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1462,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1463,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1464,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1465,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1466,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1467,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1468,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1469,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1470,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1471,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1472,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1473,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1474,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1475,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1476,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1477,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,BCBS,BLUE CROSS BLUE SHIELD, 52.39,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1478,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1479,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1480,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1481,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1482,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,BCBS,BLUE CROSS BLUE SHIELD, 27.29,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1483,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1484,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1485,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1486,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1487,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1488,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1489,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1490,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1491,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1492,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1493,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1494,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1495,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1496,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1497,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1498,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1499,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1500,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1501,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 318.54,,OUTPCT LIMIT, 189.29,OTHER, 26.45, 367.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1502,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,BCBS,BLUE CROSS BLUE SHIELD, 194.49,,OUTPCT LIMIT, 115.17,OTHER, 14.46, 224.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1503,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,BCBS,BLUE CROSS BLUE SHIELD, 113.31,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1504,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,BCBS,BLUE CROSS BLUE SHIELD, 191.49,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1505,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,BCBS,BLUE CROSS BLUE SHIELD, 78.48,,OUTPCT LIMIT, 48.91,OTHER, 16.07, 90.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1506,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 74.38,,OUTPCT LIMIT, 45.23,OTHER, 10.51, 85.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1507,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,BCBS,BLUE CROSS BLUE SHIELD, 26.64,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1508,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,BCBS,BLUE CROSS BLUE SHIELD, 26.64,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1509,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 95.41,,OUTPCT LIMIT, 59.25,OTHER, 18.65, 110.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1510,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,BCBS,BLUE CROSS BLUE SHIELD, 148.40,,OUTPCT LIMIT, 93.98,OTHER, 36.65, 171.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1511,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,BCBS,BLUE CROSS BLUE SHIELD, 223.93,,OUTPCT LIMIT, 137.37,OTHER, 36.65, 258.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1512,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 126.99,,OUTPCT LIMIT, 78.46,OTHER, 23.14, 146.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1513,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,BCBS,BLUE CROSS BLUE SHIELD, 110.72,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1514,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,BCBS,BLUE CROSS BLUE SHIELD, 110.44,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1515,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 123.11,,OUTPCT LIMIT, 77.69,OTHER, 29.26, 141.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1516,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,BCBS,BLUE CROSS BLUE SHIELD, 102.26,,OUTPCT LIMIT, 63.19,OTHER, 18.65, 117.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1517,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 102.11,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1518,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,BCBS,BLUE CROSS BLUE SHIELD, 110.85,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1519,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,BCBS,BLUE CROSS BLUE SHIELD, 120.23,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1520,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,BCBS,BLUE CROSS BLUE SHIELD, 120.23,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1521,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,BCBS,BLUE CROSS BLUE SHIELD, 120.23,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1522,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,BCBS,BLUE CROSS BLUE SHIELD, 120.23,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1523,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,BCBS,BLUE CROSS BLUE SHIELD, 120.38,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1524,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,BCBS,BLUE CROSS BLUE SHIELD, 120.23,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1525,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,BCBS,BLUE CROSS BLUE SHIELD, 102.72,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1526,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,BCBS,BLUE CROSS BLUE SHIELD, 95.76,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1527,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 135.15,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1528,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,BCBS,BLUE CROSS BLUE SHIELD, 206.69,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1529,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 199.54,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1530,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 21.25,,OUTPCT LIMIT, 15.65,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1531,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,BCBS,BLUE CROSS BLUE SHIELD, 126.68,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1532,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,BCBS,BLUE CROSS BLUE SHIELD, 130.25,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1533,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,BCBS,BLUE CROSS BLUE SHIELD, 135.75,,OUTPCT LIMIT, 85.12,OTHER, 29.96, 156.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1534,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,BCBS,BLUE CROSS BLUE SHIELD, 167.65,,OUTPCT LIMIT, 103.45,OTHER, 29.96, 193.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1535,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,BCBS,BLUE CROSS BLUE SHIELD, 115.01,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1536,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 299.63,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1537,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,BCBS,BLUE CROSS BLUE SHIELD, 84.88,,OUTPCT LIMIT, 50.54,OTHER, 7.46, 97.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1538,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,BCBS,BLUE CROSS BLUE SHIELD, 141.36,,OUTPCT LIMIT, 88.87,OTHER, 32.17, 162.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1539,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 102.85,,OUTPCT LIMIT, 66.43,OTHER, 30.83, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1540,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,BCBS,BLUE CROSS BLUE SHIELD, 90.96,,OUTPCT LIMIT, 57.43,OTHER, 21.72, 104.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1541,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 447.31,,OUTPCT LIMIT, 265.06,OTHER, 33.95, 515.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1542,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 124.95,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1543,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 124.95,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1544,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 172.13,,OUTPCT LIMIT, 111.82,OTHER, 54.34, 198.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1545,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 278.72,,OUTPCT LIMIT, 176.22,OTHER, 67.64, 321.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1546,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 137.28,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1547,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 137.28,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1548,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 113.90,,OUTPCT LIMIT, 68.73,OTHER, 13.84, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1549,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,BCBS,BLUE CROSS BLUE SHIELD, 138.65,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1550,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 178.50,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1551,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 113.90,,OUTPCT LIMIT, 70.10,OTHER, 19.60, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1552,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,BCBS,BLUE CROSS BLUE SHIELD, 78.18,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1553,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,BCBS,BLUE CROSS BLUE SHIELD, 78.18,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1554,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 296.65,,OUTPCT LIMIT, 191.67,OTHER, 89.24, 342.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1555,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,BCBS,BLUE CROSS BLUE SHIELD, 15.90,,OUTPCT LIMIT, 12.31,OTHER, 8.04, 18.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1556,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,BCBS,BLUE CROSS BLUE SHIELD, 29.67,,OUTPCT LIMIT, 18.56,OTHER, 6.34, 34.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1557,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,BCBS,BLUE CROSS BLUE SHIELD, 54.04,,OUTPCT LIMIT, 36.21,OTHER, 21.67, 62.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1558,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 90.10,,OUTPCT LIMIT, 55.25,OTHER, 14.66, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1559,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,BCBS,BLUE CROSS BLUE SHIELD, 62.15,,OUTPCT LIMIT, 40.13,OTHER, 18.58, 71.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1560,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 107.95,,OUTPCT LIMIT, 66.54,OTHER, 19.00, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1561,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,BCBS,BLUE CROSS BLUE SHIELD, 143.68,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1562,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,BCBS,BLUE CROSS BLUE SHIELD, 143.68,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1563,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,BCBS,BLUE CROSS BLUE SHIELD, 143.68,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1564,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,BCBS,BLUE CROSS BLUE SHIELD, 39.39,,OUTPCT LIMIT, 26.75,OTHER, 17.29, 45.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1565,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,BCBS,BLUE CROSS BLUE SHIELD, 82.39,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1566,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 221.00,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1567,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 79.90,,OUTPCT LIMIT, 50.83,OTHER, 20.72, 92.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1568,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 92.65,,OUTPCT LIMIT, 59.00,OTHER, 24.26, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1569,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,BCBS,BLUE CROSS BLUE SHIELD, 103.07,,OUTPCT LIMIT, 64.46,OTHER, 22.02, 118.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1570,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,BCBS,BLUE CROSS BLUE SHIELD, 92.74,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1571,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,BCBS,BLUE CROSS BLUE SHIELD, 92.74,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1572,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,BCBS,BLUE CROSS BLUE SHIELD, 155.53,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1573,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 93.61,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1574,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 93.61,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1575,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 104.55,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1576,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 104.55,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1577,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 67.15,,OUTPCT LIMIT, 43.51,OTHER, 20.72, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1578,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,BCBS,BLUE CROSS BLUE SHIELD, 75.12,,OUTPCT LIMIT, 47.68,OTHER, 19.00, 86.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1579,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 90.10,,OUTPCT LIMIT, 58.39,OTHER, 27.86, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1580,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,BCBS,BLUE CROSS BLUE SHIELD, 126.62,,OUTPCT LIMIT, 77.47,OTHER, 19.86, 145.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1581,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,BCBS,BLUE CROSS BLUE SHIELD, 100.61,,OUTPCT LIMIT, 62.50,OTHER, 19.74, 116.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1582,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,BCBS,BLUE CROSS BLUE SHIELD, 74.18,,OUTPCT LIMIT, 46.75,OTHER, 17.35, 85.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1583,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 64.60,,OUTPCT LIMIT, 41.14,OTHER, 16.94, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1584,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 110.36,,OUTPCT LIMIT, 67.08,OTHER, 15.47, 127.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1585,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,BCBS,BLUE CROSS BLUE SHIELD, 80.55,,OUTPCT LIMIT, 50.52,OTHER, 17.84, 92.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1586,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,BCBS,BLUE CROSS BLUE SHIELD, 42.33,,OUTPCT LIMIT, 28.18,OTHER, 16.21, 48.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1587,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,BCBS,BLUE CROSS BLUE SHIELD, 83.67,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1588,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,BCBS,BLUE CROSS BLUE SHIELD, 83.67,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1589,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 63.75,,OUTPCT LIMIT, 41.16,OTHER, 19.07, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1590,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,BCBS,BLUE CROSS BLUE SHIELD, 71.68,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1591,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,BCBS,BLUE CROSS BLUE SHIELD, 71.68,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1592,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,BCBS,BLUE CROSS BLUE SHIELD, 71.68,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1593,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 74.16,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1594,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 76.71,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1595,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 76.71,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1596,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 78.06,,OUTPCT LIMIT, 49.38,OTHER, 19.07, 89.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1597,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,BCBS,BLUE CROSS BLUE SHIELD, 131.76,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1598,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,BCBS,BLUE CROSS BLUE SHIELD, 131.76,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1599,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,BCBS,BLUE CROSS BLUE SHIELD, 622.02,,OUTPCT LIMIT, 361.76,OTHER, 18.55, 717.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1600,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 272.85,,OUTPCT LIMIT, 161.64,OTHER, 20.54, 314.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1601,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,BCBS,BLUE CROSS BLUE SHIELD, 237.80,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1602,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,BCBS,BLUE CROSS BLUE SHIELD, 237.80,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1603,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 129.97,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1604,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 129.97,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1605,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 129.97,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1606,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 203.15,,OUTPCT LIMIT, 152.44,OTHER, 102.77, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1607,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,BCBS,BLUE CROSS BLUE SHIELD, 366.23,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1608,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,BCBS,BLUE CROSS BLUE SHIELD, 366.23,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1609,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,BCBS,BLUE CROSS BLUE SHIELD, 366.23,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1610,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,BCBS,BLUE CROSS BLUE SHIELD, 139.11,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1611,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,BCBS,BLUE CROSS BLUE SHIELD, 139.11,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1612,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,BCBS,BLUE CROSS BLUE SHIELD, 139.11,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1613,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,BCBS,BLUE CROSS BLUE SHIELD, 139.11,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1614,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,BCBS,BLUE CROSS BLUE SHIELD, 139.11,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1615,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,BCBS,BLUE CROSS BLUE SHIELD, 252.54,,OUTPCT LIMIT, 146.86,OTHER, 7.46, 291.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1616,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 93.50,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1617,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 93.50,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1618,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 93.50,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1619,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,BCBS,BLUE CROSS BLUE SHIELD, 77.42,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1620,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.58,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1621,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,BCBS,BLUE CROSS BLUE SHIELD, 77.42,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1622,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,BCBS,BLUE CROSS BLUE SHIELD, 366.23,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1623,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,BCBS,BLUE CROSS BLUE SHIELD, 366.23,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1624,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 332.78,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1625,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 118.58,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1626,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 118.58,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1627,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,BCBS,BLUE CROSS BLUE SHIELD, 505.09,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1628,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,BCBS,BLUE CROSS BLUE SHIELD, 505.09,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1629,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,BCBS,BLUE CROSS BLUE SHIELD, 505.09,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1630,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,BCBS,BLUE CROSS BLUE SHIELD, 505.09,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1631,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,BCBS,BLUE CROSS BLUE SHIELD, 505.09,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1632,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,BCBS,BLUE CROSS BLUE SHIELD, 505.09,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1633,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 118.58,,OUTPCT LIMIT, 76.50,OTHER, 35.20, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1634,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 221.85,,OUTPCT LIMIT, 149.18,OTHER, 91.25, 255.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1635,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,BCBS,BLUE CROSS BLUE SHIELD, 135.54,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1636,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,BCBS,BLUE CROSS BLUE SHIELD, 135.54,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1637,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,BCBS,BLUE CROSS BLUE SHIELD, 47.91,,OUTPCT LIMIT, 30.76,OTHER, 13.60, 55.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1638,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,BCBS,BLUE CROSS BLUE SHIELD, 121.30,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1639,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,BCBS,BLUE CROSS BLUE SHIELD, 121.30,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1640,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,BCBS,BLUE CROSS BLUE SHIELD, 130.58,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1641,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,BCBS,BLUE CROSS BLUE SHIELD, 130.58,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1642,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,BCBS,BLUE CROSS BLUE SHIELD, 132.68,,OUTPCT LIMIT, 78.99,OTHER, 11.64, 152.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1643,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,BCBS,BLUE CROSS BLUE SHIELD, 76.59,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1644,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,BCBS,BLUE CROSS BLUE SHIELD, 76.59,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1645,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,BCBS,BLUE CROSS BLUE SHIELD, 76.59,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1646,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,BCBS,BLUE CROSS BLUE SHIELD, 67.35,,OUTPCT LIMIT, 40.96,OTHER, 9.55, 77.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1647,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.96,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1648,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.96,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1649,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.96,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1650,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,BCBS,BLUE CROSS BLUE SHIELD, 138.36,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1651,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,BCBS,BLUE CROSS BLUE SHIELD, 138.36,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1652,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,BCBS,BLUE CROSS BLUE SHIELD, 125.09,,OUTPCT LIMIT, 74.74,OTHER, 12.11, 144.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1653,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,BCBS,BLUE CROSS BLUE SHIELD, 151.96,,OUTPCT LIMIT, 91.00,OTHER, 15.55, 175.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1654,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,BCBS,BLUE CROSS BLUE SHIELD, 113.59,,OUTPCT LIMIT, 68.31,OTHER, 12.82, 130.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1655,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 28.05,,OUTPCT LIMIT, 17.74,OTHER, 6.84, 32.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1656,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,BCBS,BLUE CROSS BLUE SHIELD, 35.56,,OUTPCT LIMIT, 22.99,OTHER, 10.78, 40.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1657,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 49.30,,OUTPCT LIMIT, 29.95,OTHER, 6.84, 56.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1658,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,BCBS,BLUE CROSS BLUE SHIELD, 68.66,,OUTPCT LIMIT, 42.41,OTHER, 12.46, 79.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1659,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,BCBS,BLUE CROSS BLUE SHIELD, 48.10,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1660,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,BCBS,BLUE CROSS BLUE SHIELD, 44.79,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1661,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,BCBS,BLUE CROSS BLUE SHIELD, 44.79,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1662,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,BCBS,BLUE CROSS BLUE SHIELD, 44.96,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1663,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,BCBS,BLUE CROSS BLUE SHIELD, 44.96,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1664,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,BCBS,BLUE CROSS BLUE SHIELD, 63.18,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1665,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,BCBS,BLUE CROSS BLUE SHIELD, 63.18,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1666,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,BCBS,BLUE CROSS BLUE SHIELD, 45.77,,OUTPCT LIMIT, 28.29,OTHER, 8.38, 52.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1667,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 107.95,,OUTPCT LIMIT, 68.72,OTHER, 28.16, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1668,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,BCBS,BLUE CROSS BLUE SHIELD, 514.00,,OUTPCT LIMIT, 299.39,OTHER, 17.26, 592.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1669,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,BCBS,BLUE CROSS BLUE SHIELD, 64.62,,OUTPCT LIMIT, 40.67,OTHER, 14.88, 74.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1670,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,BCBS,BLUE CROSS BLUE SHIELD, 68.10,,OUTPCT LIMIT, 43.08,OTHER, 16.61, 78.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1671,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 203.15,,OUTPCT LIMIT, 121.25,OTHER, 19.08, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1672,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 107.95,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1673,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 164.05,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1674,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,BCBS,BLUE CROSS BLUE SHIELD, 164.06,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1675,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 164.05,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1676,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 164.05,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1677,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 164.05,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1678,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,BCBS,BLUE CROSS BLUE SHIELD, 320.58,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1679,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,BCBS,BLUE CROSS BLUE SHIELD, 320.58,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1680,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 133.56,,OUTPCT LIMIT, 100.71,OTHER, 67.57, 153.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1681,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,BCBS,BLUE CROSS BLUE SHIELD, 359.95,,OUTPCT LIMIT, 221.47,OTHER, 61.69, 415.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1682,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,BCBS,BLUE CROSS BLUE SHIELD, 112.11,,OUTPCT LIMIT, 76.43,OTHER, 50.53, 129.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1683,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 410.55,,OUTPCT LIMIT, 265.03,OTHER, 122.54, 473.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1684,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,BCBS,BLUE CROSS BLUE SHIELD, 164.06,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1685,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 127.50,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1686,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 127.50,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1687,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,BCBS,BLUE CROSS BLUE SHIELD, 527.05,,OUTPCT LIMIT, 445.68,OTHER, 266.63, 607.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1688,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 85.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1689,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 85.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1690,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 85.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1691,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,BCBS,BLUE CROSS BLUE SHIELD, 316.73,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1692,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,BCBS,BLUE CROSS BLUE SHIELD, 316.73,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1693,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1694,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 281.35,,OUTPCT LIMIT, 173.66,OTHER, 50.53, 324.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1695,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 107.95,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1696,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 148.92,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1697,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,BCBS,BLUE CROSS BLUE SHIELD, 520.15,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1698,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,BCBS,BLUE CROSS BLUE SHIELD, 229.47,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1699,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,BCBS,BLUE CROSS BLUE SHIELD, 229.47,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1700,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,BCBS,BLUE CROSS BLUE SHIELD, 98.49,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1701,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,BCBS,BLUE CROSS BLUE SHIELD, 98.49,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1702,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 67.15,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1703,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 67.15,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1704,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 67.15,,OUTPCT LIMIT, 44.25,OTHER, 23.81, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1705,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 21.25,,OUTPCT LIMIT, 17.88,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1706,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,BCBS,BLUE CROSS BLUE SHIELD, 164.72,,OUTPCT LIMIT, 100.14,OTHER, 23.14, 189.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1707,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1240.15,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1708,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1240.15,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1709,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 88.40,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1710,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 88.40,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1711,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 471.75,,OUTPCT LIMIT, 294.34,OTHER, 97.97, 543.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1712,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1713,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1714,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 26.35,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1715,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 26.35,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1716,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,BCBS,BLUE CROSS BLUE SHIELD, 95.55,,OUTPCT LIMIT, 56.81,OTHER, 8.06, 110.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1717,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,BCBS,BLUE CROSS BLUE SHIELD, 65.21,,OUTPCT LIMIT, 39.98,OTHER, 10.56, 75.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1718,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 65.45,,OUTPCT LIMIT, 41.73,OTHER, 17.35, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1719,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,BCBS,BLUE CROSS BLUE SHIELD, 5042.57,,OUTPCT LIMIT, 3802.17,OTHER, 2550.94, 5813.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1720,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,BCBS,BLUE CROSS BLUE SHIELD, 95.76,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1721,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,BCBS,BLUE CROSS BLUE SHIELD, 95.76,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1722,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 25.08,,OUTPCT LIMIT, 23.30,OTHER, 12.69, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1723,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 50.58,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1724,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 25.29,,OUTPCT LIMIT, 23.42,OTHER, 12.79, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1725,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 109.65,,OUTPCT LIMIT, 82.68,OTHER, 55.47, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1726,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1727,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 130.05,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1728,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 130.05,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1729,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 118.11,,OUTPCT LIMIT, 89.06,OTHER, 59.75, 136.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1730,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 42.50,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1731,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 42.50,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1732,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,BCBS,BLUE CROSS BLUE SHIELD, 504.38,,OUTPCT LIMIT, 356.50,OTHER, 255.16, 581.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1733,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,BCBS,BLUE CROSS BLUE SHIELD, 1053.82,,OUTPCT LIMIT, 687.64,OTHER, 345.38, 1214.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1734,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 267.33,,OUTPCT LIMIT, 201.57,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1735,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1736,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1737,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.25,,OUTPCT LIMIT, 60.00,OTHER, 36.55, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1738,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,BCBS,BLUE CROSS BLUE SHIELD, 43.73,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1739,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,BCBS,BLUE CROSS BLUE SHIELD, 43.73,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1740,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1741,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1742,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1743,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 9.35,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1744,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 9.35,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1745,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 9.35,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1746,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 9.35,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1747,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,BCBS,BLUE CROSS BLUE SHIELD, 67.78,,OUTPCT LIMIT, 51.11,OTHER, 34.29, 78.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1748,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,BCBS,BLUE CROSS BLUE SHIELD, 116.20,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1749,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,BCBS,BLUE CROSS BLUE SHIELD, 116.20,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1750,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1751,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,BCBS,BLUE CROSS BLUE SHIELD, 134.13,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1752,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,BCBS,BLUE CROSS BLUE SHIELD, 134.13,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1753,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1754,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1755,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,BCBS,BLUE CROSS BLUE SHIELD, 145.27,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1756,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,BCBS,BLUE CROSS BLUE SHIELD, 145.27,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1757,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 8.50,,OUTPCT LIMIT, 12.78,OTHER, 4.30, 33.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1758,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,BCBS,BLUE CROSS BLUE SHIELD, 28.10,,OUTPCT LIMIT, 17.36,OTHER, 5.09, 32.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1759,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,BCBS,BLUE CROSS BLUE SHIELD, 258.32,,OUTPCT LIMIT, 184.48,OTHER, 130.68, 297.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1760,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,BCBS,BLUE CROSS BLUE SHIELD, 289.43,,OUTPCT LIMIT, 202.35,OTHER, 146.42, 333.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1761,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,BCBS,BLUE CROSS BLUE SHIELD, 125.75,,OUTPCT LIMIT, 99.37,OTHER, 63.61, 144.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1762,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,BCBS,BLUE CROSS BLUE SHIELD, 129.26,,OUTPCT LIMIT, 88.44,OTHER, 59.56, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1763,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,BCBS,BLUE CROSS BLUE SHIELD, 166.49,,OUTPCT LIMIT, 131.72,OTHER, 84.22, 191.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1764,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,BCBS,BLUE CROSS BLUE SHIELD, 163.68,,OUTPCT LIMIT, 117.05,OTHER, 82.81, 188.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1765,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,BCBS,BLUE CROSS BLUE SHIELD, 250.09,,OUTPCT LIMIT, 179.75,OTHER, 126.51, 288.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1766,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,BCBS,BLUE CROSS BLUE SHIELD, 216.37,,OUTPCT LIMIT, 158.52,OTHER, 109.46, 249.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1767,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,BCBS,BLUE CROSS BLUE SHIELD, 261.33,,OUTPCT LIMIT, 186.21,OTHER, 132.20, 301.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1768,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,BCBS,BLUE CROSS BLUE SHIELD, 125.04,,OUTPCT LIMIT, 83.96,OTHER, 50.93, 144.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1769,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 201.62,,OUTPCT LIMIT, 167.44,OTHER, 102.00, 232.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1770,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,BCBS,BLUE CROSS BLUE SHIELD, 210.04,,OUTPCT LIMIT, 172.28,OTHER, 106.26, 242.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1771,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,BCBS,BLUE CROSS BLUE SHIELD, 50.58,,OUTPCT LIMIT, 49.86,OTHER, 25.59, 87.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1772,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,BCBS,BLUE CROSS BLUE SHIELD, 210.75,,OUTPCT LIMIT, 141.43,OTHER, 85.51, 242.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1773,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.78,,OUTPCT LIMIT, 69.71,OTHER, 45.42, 103.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1774,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,BCBS,BLUE CROSS BLUE SHIELD, 238.14,,OUTPCT LIMIT, 177.65,OTHER, 120.47, 274.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1775,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,BCBS,BLUE CROSS BLUE SHIELD, 258.69,,OUTPCT LIMIT, 189.46,OTHER, 130.87, 298.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1776,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,BCBS,BLUE CROSS BLUE SHIELD, 416.18,,OUTPCT LIMIT, 279.93,OTHER, 171.54, 479.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1777,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,BCBS,BLUE CROSS BLUE SHIELD, 390.18,,OUTPCT LIMIT, 265.00,OTHER, 171.54, 449.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1778,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,BCBS,BLUE CROSS BLUE SHIELD, 213.85,,OUTPCT LIMIT, 149.90,OTHER, 108.18, 246.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1779,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,BCBS,BLUE CROSS BLUE SHIELD, 271.62,,OUTPCT LIMIT, 167.02,OTHER, 46.09, 313.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1780,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,BCBS,BLUE CROSS BLUE SHIELD, 113.36,,OUTPCT LIMIT, 76.10,OTHER, 46.09, 130.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1781,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,BCBS,BLUE CROSS BLUE SHIELD, 237.38,,OUTPCT LIMIT, 147.35,OTHER, 46.09, 273.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1782,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,BCBS,BLUE CROSS BLUE SHIELD, 344.00,,OUTPCT LIMIT, 227.22,OTHER, 124.32, 396.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1783,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 462.83,,OUTPCT LIMIT, 295.49,OTHER, 124.32, 533.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1784,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,BCBS,BLUE CROSS BLUE SHIELD, 147.60,,OUTPCT LIMIT, 114.40,OTHER, 74.67, 170.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1785,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,BCBS,BLUE CROSS BLUE SHIELD, 219.12,,OUTPCT LIMIT, 155.48,OTHER, 110.85, 252.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1786,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 33.96,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1787,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 33.96,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1788,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 33.96,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1789,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,BCBS,BLUE CROSS BLUE SHIELD, 16.62,,OUTPCT LIMIT, 36.72,OTHER, 8.41, 114.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1790,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,BCBS,BLUE CROSS BLUE SHIELD, 313.10,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1791,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,BCBS,BLUE CROSS BLUE SHIELD, 313.10,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1792,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,BCBS,BLUE CROSS BLUE SHIELD, 773.19,,OUTPCT LIMIT, 526.62,OTHER, 346.21, 891.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1793,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 290.83,OTHER, 143.52, 346.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1794,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,BCBS,BLUE CROSS BLUE SHIELD, 283.28,,OUTPCT LIMIT, 266.67,OTHER, 147.17, 326.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1795,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 261.80,,OUTPCT LIMIT, 162.12,OTHER, 49.24, 301.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1796,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 210.80,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1797,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 210.80,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1798,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 269.45,,OUTPCT LIMIT, 166.97,OTHER, 51.13, 310.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1799,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,BCBS,BLUE CROSS BLUE SHIELD, 74.47,,OUTPCT LIMIT, 54.96,OTHER, 37.67, 85.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1800,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,BCBS,BLUE CROSS BLUE SHIELD, 129.26,,OUTPCT LIMIT, 86.43,OTHER, 51.13, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1801,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 1382.68,,OUTPCT LIMIT, 950.56,OTHER, 656.16, 1594.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1802,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 375.80,OTHER, 121.44, 656.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1803,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 790.50,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1804,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 790.50,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1805,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1806,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1807,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,BCBS,BLUE CROSS BLUE SHIELD, 936.93,,OUTPCT LIMIT, 591.97,OTHER, 225.62, 1080.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1808,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1809,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,BCBS,BLUE CROSS BLUE SHIELD, 395.84,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1810,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,BCBS,BLUE CROSS BLUE SHIELD, 395.84,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1811,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 197.77,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1812,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,BCBS,BLUE CROSS BLUE SHIELD, 887.63,,OUTPCT LIMIT, 563.65,OTHER, 225.62, 1023.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1813,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1814,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 138.55,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1815,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 138.55,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1816,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1817,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1818,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 425.00,,OUTPCT LIMIT, 297.88,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1819,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1820,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 397.59,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1821,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 397.59,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1822,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1823,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1824,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,BCBS,BLUE CROSS BLUE SHIELD, 1079.04,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1825,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,BCBS,BLUE CROSS BLUE SHIELD, 1079.04,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1826,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,BCBS,BLUE CROSS BLUE SHIELD, 573.31,,OUTPCT LIMIT, 383.08,OTHER, 225.62, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1827,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,BCBS,BLUE CROSS BLUE SHIELD, 1079.04,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1828,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1829,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1830,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1831,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1832,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,BCBS,BLUE CROSS BLUE SHIELD, 573.31,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1833,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,BCBS,BLUE CROSS BLUE SHIELD, 573.31,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1834,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,BCBS,BLUE CROSS BLUE SHIELD, 573.31,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1835,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,BCBS,BLUE CROSS BLUE SHIELD, 573.31,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1836,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1837,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1838,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1839,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1840,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 1047.31,,OUTPCT LIMIT, 655.39,OTHER, 225.62, 1207.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1841,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1842,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2202.35,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1843,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,BCBS,BLUE CROSS BLUE SHIELD, 1189.56,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1844,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 370.60,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1845,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 78.20,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1846,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,BCBS,BLUE CROSS BLUE SHIELD, 895.37,,OUTPCT LIMIT, 547.41,OTHER, 138.71, 1032.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1847,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,BCBS,BLUE CROSS BLUE SHIELD, 205.35,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1848,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,BCBS,BLUE CROSS BLUE SHIELD, 205.35,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1849,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,BCBS,BLUE CROSS BLUE SHIELD, 248.65,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1850,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,BCBS,BLUE CROSS BLUE SHIELD, 248.65,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1851,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,BCBS,BLUE CROSS BLUE SHIELD, 520.51,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1852,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 682.55,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1853,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 749.70,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1854,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,BCBS,BLUE CROSS BLUE SHIELD, 520.51,,OUTPCT LIMIT, 332.46,OTHER, 140.42, 600.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1855,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,BCBS,BLUE CROSS BLUE SHIELD, 316.85,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1856,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,BCBS,BLUE CROSS BLUE SHIELD, 316.85,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1857,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,BCBS,BLUE CROSS BLUE SHIELD, 205.35,,OUTPCT LIMIT, 174.98,OTHER, 103.88, 239.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1858,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,BCBS,BLUE CROSS BLUE SHIELD, 205.35,,OUTPCT LIMIT, 136.10,OTHER, 76.16, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1859,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 147.05,,OUTPCT LIMIT, 140.33,OTHER, 74.39, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1860,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 361.25,,OUTPCT LIMIT, 228.33,OTHER, 87.35, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1861,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,BCBS,BLUE CROSS BLUE SHIELD, 45.34,,OUTPCT LIMIT, 34.19,OTHER, 22.94, 52.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1862,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 88.40,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1863,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,BCBS,BLUE CROSS BLUE SHIELD, 278.50,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1864,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,BCBS,BLUE CROSS BLUE SHIELD, 278.50,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1865,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,BCBS,BLUE CROSS BLUE SHIELD, 121.92,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1866,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,BCBS,BLUE CROSS BLUE SHIELD, 121.92,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1867,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,BCBS,BLUE CROSS BLUE SHIELD, 625.76,,OUTPCT LIMIT, 415.63,OTHER, 235.80, 721.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1868,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2762.50,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1869,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2762.50,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1870,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 3315.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1871,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 3315.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1872,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 3315.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1873,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,BCBS,BLUE CROSS BLUE SHIELD, 230.54,,OUTPCT LIMIT, 152.82,OTHER, 85.61, 265.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1874,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,BCBS,BLUE CROSS BLUE SHIELD, 251.84,,OUTPCT LIMIT, 165.98,OTHER, 89.47, 290.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1875,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,BCBS,BLUE CROSS BLUE SHIELD, 408.23,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1876,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,BCBS,BLUE CROSS BLUE SHIELD, 408.23,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1877,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 153.17,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1878,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 153.17,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1879,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,BCBS,BLUE CROSS BLUE SHIELD, 485.91,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1880,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,BCBS,BLUE CROSS BLUE SHIELD, 485.91,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1881,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,BCBS,BLUE CROSS BLUE SHIELD, 485.91,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1882,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,BCBS,BLUE CROSS BLUE SHIELD, 140.00,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1883,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,BCBS,BLUE CROSS BLUE SHIELD, 140.05,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1884,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,BCBS,BLUE CROSS BLUE SHIELD, 166.97,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1885,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,BCBS,BLUE CROSS BLUE SHIELD, 166.97,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1886,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,BCBS,BLUE CROSS BLUE SHIELD, 122.35,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1887,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,BCBS,BLUE CROSS BLUE SHIELD, 122.35,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1888,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,BCBS,BLUE CROSS BLUE SHIELD, 130.81,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1889,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,BCBS,BLUE CROSS BLUE SHIELD, 130.81,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1890,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 50.58,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1891,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 50.58,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1892,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,BCBS,BLUE CROSS BLUE SHIELD, 255.71,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1893,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,BCBS,BLUE CROSS BLUE SHIELD, 255.71,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1894,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,BCBS,BLUE CROSS BLUE SHIELD, 145.29,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1895,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,BCBS,BLUE CROSS BLUE SHIELD, 145.29,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1896,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 146.63,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1897,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 146.63,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1898,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,BCBS,BLUE CROSS BLUE SHIELD, 74.77,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1899,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,BCBS,BLUE CROSS BLUE SHIELD, 74.77,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1900,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,BCBS,BLUE CROSS BLUE SHIELD, 82.06,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1901,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,BCBS,BLUE CROSS BLUE SHIELD, 82.06,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1902,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.92,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1903,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.92,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1904,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.92,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1905,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 357.00,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1906,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,BCBS,BLUE CROSS BLUE SHIELD, 114.62,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1907,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,BCBS,BLUE CROSS BLUE SHIELD, 114.62,,OUTPCT LIMIT, 72.71,OTHER, 28.82, 132.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1908,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,BCBS,BLUE CROSS BLUE SHIELD, 104.45,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1909,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,BCBS,BLUE CROSS BLUE SHIELD, 104.38,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1910,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,BCBS,BLUE CROSS BLUE SHIELD, 104.45,,OUTPCT LIMIT, 74.35,OTHER, 52.84, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1911,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,BCBS,BLUE CROSS BLUE SHIELD, 111.40,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1912,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,BCBS,BLUE CROSS BLUE SHIELD, 111.40,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1913,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,BCBS,BLUE CROSS BLUE SHIELD, 111.40,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1914,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 80.86,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1915,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 80.86,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1916,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,BCBS,BLUE CROSS BLUE SHIELD, 57.48,,OUTPCT LIMIT, 47.68,OTHER, 29.08, 66.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1917,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 152.15,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1918,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 152.15,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1919,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 152.15,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1920,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 182.75,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1921,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 182.75,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1922,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 182.75,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1923,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 104.27,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1924,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 104.27,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1925,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,BCBS,BLUE CROSS BLUE SHIELD, 104.27,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1926,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 37.40,,OUTPCT LIMIT, 30.33,OTHER, 18.92, 43.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1927,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,BCBS,BLUE CROSS BLUE SHIELD, 225.28,,OUTPCT LIMIT, 178.52,OTHER, 113.97, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1928,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 267.33,,OUTPCT LIMIT, 202.67,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1929,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,BCBS,BLUE CROSS BLUE SHIELD, 253.10,,OUTPCT LIMIT, 194.50,OTHER, 128.04, 291.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1930,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,BCBS,BLUE CROSS BLUE SHIELD, 126.11,,OUTPCT LIMIT, 106.37,OTHER, 63.79, 145.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1931,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,BCBS,BLUE CROSS BLUE SHIELD, 216.18,,OUTPCT LIMIT, 173.75,OTHER, 109.36, 249.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1932,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,BCBS,BLUE CROSS BLUE SHIELD, 228.51,,OUTPCT LIMIT, 180.83,OTHER, 115.60, 263.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1933,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,BCBS,BLUE CROSS BLUE SHIELD, 269.70,,OUTPCT LIMIT, 204.49,OTHER, 136.43, 310.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1934,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,BCBS,BLUE CROSS BLUE SHIELD, 130.25,,OUTPCT LIMIT, 108.91,OTHER, 65.89, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1935,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,BCBS,BLUE CROSS BLUE SHIELD, 102.60,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1936,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,BCBS,BLUE CROSS BLUE SHIELD, 102.60,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1937,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,BCBS,BLUE CROSS BLUE SHIELD, 102.60,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1938,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 62.39,,OUTPCT LIMIT, 44.69,OTHER, 31.56, 71.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1939,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,BCBS,BLUE CROSS BLUE SHIELD, 108.50,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1940,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,BCBS,BLUE CROSS BLUE SHIELD, 108.50,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1941,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,BCBS,BLUE CROSS BLUE SHIELD, 75.33,,OUTPCT LIMIT, 59.17,OTHER, 38.11, 86.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1942,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 98.60,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1943,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 98.60,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1944,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 98.60,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1945,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 24.65,,OUTPCT LIMIT, 68.90,OTHER, 12.81, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1946,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,BCBS,BLUE CROSS BLUE SHIELD, 122.20,,OUTPCT LIMIT, 93.12,OTHER, 61.82, 140.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1947,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 102.85,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1948,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,BCBS,BLUE CROSS BLUE SHIELD, 225.28,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1949,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 105.40,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1950,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 105.40,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1951,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 105.40,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1952,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 63.75,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1953,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 88.40,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1954,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 119.85,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1955,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 88.40,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1956,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 119.85,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1957,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 63.75,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1958,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 63.75,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1959,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 255.00,,OUTPCT LIMIT, 192.27,OTHER, 129.00, 294.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1960,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1961,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1962,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,BCBS,BLUE CROSS BLUE SHIELD, 205.35,,OUTPCT LIMIT, 145.27,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1963,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 126.44,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1964,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 126.44,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1965,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,BCBS,BLUE CROSS BLUE SHIELD, 214.26,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1966,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,BCBS,BLUE CROSS BLUE SHIELD, 214.26,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1967,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 335.24,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1968,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 335.24,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1969,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,BCBS,BLUE CROSS BLUE SHIELD, 417.61,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1970,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,BCBS,BLUE CROSS BLUE SHIELD, 417.61,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1971,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 40.46,,OUTPCT LIMIT, 30.51,OTHER, 20.47, 46.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1972,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,BCBS,BLUE CROSS BLUE SHIELD, 88.15,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1973,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,BCBS,BLUE CROSS BLUE SHIELD, 88.15,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1974,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 147.39,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1975,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 147.39,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1976,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,BCBS,BLUE CROSS BLUE SHIELD, 217.47,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1977,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,BCBS,BLUE CROSS BLUE SHIELD, 217.47,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1978,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,BCBS,BLUE CROSS BLUE SHIELD, 291.17,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1979,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,BCBS,BLUE CROSS BLUE SHIELD, 291.17,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1980,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 289.00,,OUTPCT LIMIT, 272.06,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1981,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 357.85,,OUTPCT LIMIT, 336.87,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1982,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 123.25,,OUTPCT LIMIT, 111.61,OTHER, 64.03, 142.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1983,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 150.45,,OUTPCT LIMIT, 149.82,OTHER, 78.16, 173.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1984,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 217.60,,OUTPCT LIMIT, 220.11,OTHER, 113.05, 250.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1985,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,BCBS,BLUE CROSS BLUE SHIELD, 228.58,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1986,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,BCBS,BLUE CROSS BLUE SHIELD, 228.58,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1987,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 213.35,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1988,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 213.35,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1989,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 353.60,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1990,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 353.60,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1991,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 251.60,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1992,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 251.60,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1993,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,BCBS,BLUE CROSS BLUE SHIELD, 558.74,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1994,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,BCBS,BLUE CROSS BLUE SHIELD, 558.74,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1995,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 289.00,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1996,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 289.00,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1997,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,BCBS,BLUE CROSS BLUE SHIELD, 876.41,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1998,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,BCBS,BLUE CROSS BLUE SHIELD, 876.41,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 1999,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 357.85,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2000,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 357.85,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2001,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,BCBS,BLUE CROSS BLUE SHIELD, 1461.81,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2002,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,BCBS,BLUE CROSS BLUE SHIELD, 1461.81,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2003,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 425.85,,OUTPCT LIMIT, 429.06,OTHER, 221.24, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2004,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,BCBS,BLUE CROSS BLUE SHIELD, 2338.16,,OUTPCT LIMIT, 1514.86,OTHER, 720.78, 2695.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2005,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,BCBS,BLUE CROSS BLUE SHIELD, 857.15,,OUTPCT LIMIT, 646.30,OTHER, 433.62, 988.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2006,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 25.50,,OUTPCT LIMIT, 19.23,OTHER, 12.90, 29.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2007,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,BCBS,BLUE CROSS BLUE SHIELD, 142.33,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2008,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,BCBS,BLUE CROSS BLUE SHIELD, 142.33,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2009,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 223.98,,OUTPCT LIMIT, 167.97,OTHER, 113.31, 258.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2010,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.37,,OUTPCT LIMIT, 173.37,OTHER, 118.06, 269.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2011,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,BCBS,BLUE CROSS BLUE SHIELD, 243.48,,OUTPCT LIMIT, 179.18,OTHER, 123.17, 280.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2012,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,BCBS,BLUE CROSS BLUE SHIELD, 275.27,,OUTPCT LIMIT, 197.44,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2013,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 267.33,,OUTPCT LIMIT, 192.88,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2014,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,BCBS,BLUE CROSS BLUE SHIELD, 308.51,,OUTPCT LIMIT, 232.62,OTHER, 156.07, 355.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2015,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 335.24,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2016,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,BCBS,BLUE CROSS BLUE SHIELD, 201.58,,OUTPCT LIMIT, 155.10,OTHER, 101.97, 232.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2017,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,BCBS,BLUE CROSS BLUE SHIELD, 215.31,,OUTPCT LIMIT, 162.99,OTHER, 108.92, 248.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2018,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 234.81,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2019,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 234.81,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2020,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 234.81,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2021,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 239.87,,OUTPCT LIMIT, 177.10,OTHER, 121.35, 276.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2022,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,BCBS,BLUE CROSS BLUE SHIELD, 255.77,,OUTPCT LIMIT, 192.85,OTHER, 129.39, 294.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2023,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,BCBS,BLUE CROSS BLUE SHIELD, 275.27,,OUTPCT LIMIT, 207.56,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2024,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,BCBS,BLUE CROSS BLUE SHIELD, 73.70,,OUTPCT LIMIT, 55.57,OTHER, 37.28, 84.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2025,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 126.44,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2026,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 59.50,,OUTPCT LIMIT, 44.86,OTHER, 30.10, 68.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2027,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,BCBS,BLUE CROSS BLUE SHIELD, 226.14,,OUTPCT LIMIT, 170.52,OTHER, 114.40, 260.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2028,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,BCBS,BLUE CROSS BLUE SHIELD, 44.95,,OUTPCT LIMIT, 33.14,OTHER, 22.74, 51.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2029,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,BCBS,BLUE CROSS BLUE SHIELD, 55.63,,OUTPCT LIMIT, 39.28,OTHER, 28.14, 64.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2030,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,BCBS,BLUE CROSS BLUE SHIELD, 80.22,,OUTPCT LIMIT, 60.49,OTHER, 40.58, 92.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2031,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 18.70,,OUTPCT LIMIT, 14.10,OTHER, 9.46, 21.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2032,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 18.70,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2033,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 126.44,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2034,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 216.75,,OUTPCT LIMIT, 148.65,OTHER, 101.33, 249.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2035,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.75,,OUTPCT LIMIT, 166.04,OTHER, 118.25, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2036,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 10.84,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2037,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 10.84,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2038,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 327.25,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2039,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 327.25,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2040,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 515.95,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2041,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 515.95,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2042,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 301.75,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2043,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 301.75,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2044,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 435.20,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2045,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 435.20,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2046,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 746.30,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2047,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 746.30,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2048,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 828.75,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2049,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 828.75,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2050,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 115.60,,OUTPCT LIMIT, 87.16,OTHER, 58.48, 133.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2051,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 54.40,,OUTPCT LIMIT, 41.02,OTHER, 27.52, 62.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2052,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 63.75,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2053,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2546.60,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2054,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2546.60,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2055,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2771.85,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2056,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2771.85,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2057,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1955.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2058,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1955.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2059,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1955.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2060,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1700.00,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2061,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1700.00,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2062,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1700.00,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2063,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1700.00,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2064,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,BCBS,BLUE CROSS BLUE SHIELD, 16.27,,OUTPCT LIMIT, 9.74,OTHER, 1.66, 18.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2065,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,BCBS,BLUE CROSS BLUE SHIELD, 95.76,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2066,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 5.10,,OUTPCT LIMIT, 11.82,OTHER, 2.58, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2067,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,BCBS,BLUE CROSS BLUE SHIELD, 76.59,,OUTPCT LIMIT, 57.75,OTHER, 38.74, 88.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2068,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 39.74,,OUTPCT LIMIT, 29.96,OTHER, 20.10, 45.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2069,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,BCBS,BLUE CROSS BLUE SHIELD, 140.51,,OUTPCT LIMIT, 88.75,OTHER, 33.71, 162.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2070,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 88.40,,OUTPCT LIMIT, 58.81,OTHER, 33.71, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2071,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 332.35,,OUTPCT LIMIT, 250.60,OTHER, 168.13, 383.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2072,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 335.24,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2073,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 335.24,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2074,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,BCBS,BLUE CROSS BLUE SHIELD, 36.13,,OUTPCT LIMIT, 35.44,OTHER, 18.28, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2075,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,BCBS,BLUE CROSS BLUE SHIELD, 52.02,,OUTPCT LIMIT, 44.57,OTHER, 26.32, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2076,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 57.80,,OUTPCT LIMIT, 43.58,OTHER, 29.24, 66.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2077,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2078,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,BCBS,BLUE CROSS BLUE SHIELD, 220.83,,OUTPCT LIMIT, 166.51,OTHER, 111.71, 254.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2079,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,BCBS,BLUE CROSS BLUE SHIELD, 79.70,,OUTPCT LIMIT, 60.10,OTHER, 40.32, 91.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2080,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 6.53,,OUTPCT LIMIT, 4.92,OTHER, 3.30, 7.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2081,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,BCBS,BLUE CROSS BLUE SHIELD, 6.32,,OUTPCT LIMIT, 4.77,OTHER, 3.20, 7.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2082,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,BCBS,BLUE CROSS BLUE SHIELD, 17.27,,OUTPCT LIMIT, 13.02,OTHER, 8.74, 19.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2083,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 178.50,,OUTPCT LIMIT, 134.59,OTHER, 90.30, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2084,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,BCBS,BLUE CROSS BLUE SHIELD, 1.80,,OUTPCT LIMIT, 1.36,OTHER, .91, 2.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2085,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,BCBS,BLUE CROSS BLUE SHIELD, 2.79,,OUTPCT LIMIT, 2.10,OTHER, 1.41, 3.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2086,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,BCBS,BLUE CROSS BLUE SHIELD, 34.37,,OUTPCT LIMIT, 25.91,OTHER, 17.38, 39.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2087,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,BCBS,BLUE CROSS BLUE SHIELD, 123.34,,OUTPCT LIMIT, 93.00,OTHER, 62.40, 142.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2088,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,BCBS,BLUE CROSS BLUE SHIELD, 1.94,,OUTPCT LIMIT, 1.46,OTHER, .98, 2.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2089,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,BCBS,BLUE CROSS BLUE SHIELD, 1.36,,OUTPCT LIMIT, 1.03,OTHER, .69, 1.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2090,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,BCBS,BLUE CROSS BLUE SHIELD, 6.83,,OUTPCT LIMIT, 5.15,OTHER, 3.46, 7.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2091,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,BCBS,BLUE CROSS BLUE SHIELD, 15.20,,OUTPCT LIMIT, 11.46,OTHER, 7.69, 17.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2092,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,BCBS,BLUE CROSS BLUE SHIELD, 5.81,,OUTPCT LIMIT, 4.38,OTHER, 2.94, 6.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2093,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 3.40,,OUTPCT LIMIT, 2.56,OTHER, 1.72, 3.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2094,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,BCBS,BLUE CROSS BLUE SHIELD, 9.93,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2095,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 11.05,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2096,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,BCBS,BLUE CROSS BLUE SHIELD, 58.07,,OUTPCT LIMIT, 43.79,OTHER, 29.38, 66.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2097,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,BCBS,BLUE CROSS BLUE SHIELD, 30.53,,OUTPCT LIMIT, 23.02,OTHER, 15.45, 35.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2098,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 8.94,,OUTPCT LIMIT, 6.74,OTHER, 4.52, 10.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2099,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,BCBS,BLUE CROSS BLUE SHIELD, 6.90,,OUTPCT LIMIT, 5.20,OTHER, 3.49, 7.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2100,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 339.15,,OUTPCT LIMIT, 575.18,OTHER, 171.57, 1597.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2101,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 339.15,,OUTPCT LIMIT, 690.66,OTHER, 171.57, 2082.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2102,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 339.15,,OUTPCT LIMIT, 656.15,OTHER, 171.57, 1937.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2103,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 339.15,,OUTPCT LIMIT, 607.70,OTHER, 171.57, 1734.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2104,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 424.15,,OUTPCT LIMIT, 735.35,OTHER, 214.57, 2065.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2105,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 726.75,,OUTPCT LIMIT, 421.89,OTHER, 18.42, 837.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2106,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,BCBS,BLUE CROSS BLUE SHIELD, 4.08,,OUTPCT LIMIT, 3.08,OTHER, 2.06, 4.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2107,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2108,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2109,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2110,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2111,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2112,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2113,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2114,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2115,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2116,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2117,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2118,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2119,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 352.75,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2120,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 352.75,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2121,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 352.75,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2122,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 352.75,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2123,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2124,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2125,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2126,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2127,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2128,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2129,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2130,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2131,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2132,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2133,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2134,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2135,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2136,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2137,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2138,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2139,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2140,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2141,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2142,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2143,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,BCBS,BLUE CROSS BLUE SHIELD, 90.31,,OUTPCT LIMIT, 62.01,OTHER, 42.53, 104.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2144,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 96.90,,OUTPCT LIMIT, 73.06,OTHER, 49.02, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2145,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 85.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2146,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 425.00,,OUTPCT LIMIT, 320.46,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2147,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 35.70,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2148,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2.55,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2149,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 29.75,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2150,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2.55,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2151,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 22.95,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2152,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2.55,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2153,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 12.75,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2154,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,BCBS,BLUE CROSS BLUE SHIELD, 2.68,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2155,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 63.75,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2156,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,BCBS,BLUE CROSS BLUE SHIELD, 2.68,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2157,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 3.84,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2158,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 85.85,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2159,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 5.10,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2160,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 5.10,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2161,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,BCBS,BLUE CROSS BLUE SHIELD, 156.33,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2162,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 5.10,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2163,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 153.00,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2164,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 49.30,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2165,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 49.30,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2166,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,BCBS,BLUE CROSS BLUE SHIELD, 282.34,,OUTPCT LIMIT, 212.89,OTHER, 142.83, 325.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2167,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,BCBS,BLUE CROSS BLUE SHIELD, 103.52,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2168,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 63.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2169,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,BCBS,BLUE CROSS BLUE SHIELD, 836.94,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2170,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,BCBS,BLUE CROSS BLUE SHIELD, 609.48,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2171,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 7.65,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2172,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 5.10,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2173,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 85.85,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2174,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 85.85,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2175,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 85.85,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2176,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 85.85,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2177,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 85.85,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2178,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 85.85,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2179,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 85.85,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2180,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 5.10,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2181,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 85.85,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2182,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 86.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2183,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,BCBS,BLUE CROSS BLUE SHIELD, 61.06,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2184,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,BCBS,BLUE CROSS BLUE SHIELD, 61.06,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2185,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 63.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2186,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,BCBS,BLUE CROSS BLUE SHIELD, 116.94,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2187,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2.55,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2188,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 12.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2189,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 12.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2190,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 12.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2191,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 15.30,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2192,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 20.40,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2193,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2.55,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2194,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 24.24,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2195,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,BCBS,BLUE CROSS BLUE SHIELD, 24.24,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2196,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 25.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2197,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 25.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2198,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 25.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2199,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 25.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2200,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2.55,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2201,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,BCBS,BLUE CROSS BLUE SHIELD, 2.54,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2202,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,BCBS,BLUE CROSS BLUE SHIELD, 39.52,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2203,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 8.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2204,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,BCBS,BLUE CROSS BLUE SHIELD, 2.68,,OUTPCT LIMIT, 2.02,OTHER, 1.35, 3.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2205,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 425.85,,OUTPCT LIMIT, 321.10,OTHER, 215.43, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2206,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 486.20,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2207,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2208,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2209,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2210,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2211,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2212,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2213,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2214,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,BCBS,BLUE CROSS BLUE SHIELD, 28.93,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2215,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,BCBS,BLUE CROSS BLUE SHIELD, 129.36,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2216,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,BCBS,BLUE CROSS BLUE SHIELD, 121.24,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2217,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,BCBS,BLUE CROSS BLUE SHIELD, 79.21,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2218,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,BCBS,BLUE CROSS BLUE SHIELD, 72.71,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2219,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,BCBS,BLUE CROSS BLUE SHIELD, 221.25,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2220,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,BCBS,BLUE CROSS BLUE SHIELD, 6464.85,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2221,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,BCBS,BLUE CROSS BLUE SHIELD, 38.44,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2222,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2223,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2224,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2225,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2226,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2227,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2228,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 2040.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2229,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2230,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2231,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2232,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2233,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2234,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2235,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1190.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2236,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1190.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2237,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 1190.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2238,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2239,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2240,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2241,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2242,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2243,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,BCBS,BLUE CROSS BLUE SHIELD, 57.06,,OUTPCT LIMIT, 43.03,OTHER, 28.87, 65.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2244,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 8.50,,OUTPCT LIMIT, 6.41,OTHER, 4.30, 9.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2245,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 4930.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2246,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 4080.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2247,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 4080.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2248,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 4080.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2249,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2250,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2251,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 370.60,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2252,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,BCBS,BLUE CROSS BLUE SHIELD, 250.09,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2253,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,BCBS,BLUE CROSS BLUE SHIELD, 257.81,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2254,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,BCBS,BLUE CROSS BLUE SHIELD, 210.04,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2255,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,BCBS,BLUE CROSS BLUE SHIELD, 233.37,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2256,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 481.95,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2257,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,BCBS,BLUE CROSS BLUE SHIELD, 147.39,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2258,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 85.85,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2259,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,BCBS,BLUE CROSS BLUE SHIELD, 86.41,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2260,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,BCBS,BLUE CROSS BLUE SHIELD, 126.44,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2261,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 14.45,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2262,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 23.80,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2263,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2264,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2265,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2266,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2267,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2268,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2269,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2270,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2271,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2272,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2273,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2274,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2275,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,BCBS,BLUE CROSS BLUE SHIELD, 276.25,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2276,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBS,BLUE CROSS BLUE SHIELD, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 2277,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2278,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2279,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2280,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2281,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2282,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2283,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2284,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2285,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2286,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2287,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2288,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2289,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2290,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2291,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2292,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2293,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2294,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2295,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 271.70,OTHER, 142.76, 477.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2296,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 271.70,OTHER, 142.76, 477.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2297,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 168.89,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2298,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 171.36,OTHER, 103.33, 229.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2299,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 273.87,OTHER, 142.76, 481.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2300,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 276.81,OTHER, 142.76, 430.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2301,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 274.44,,CLAIM ADJUSTMENT 3, 242.16,OTHER, 155.70, 354.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2302,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 850.02,OTHER, 203.58, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2303,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1237.88,,CLAIM ADJUSTMENT 3, 667.92,OTHER, 193.86, 1237.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2304,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 274.44,,CLAIM ADJUSTMENT 3, 177.23,OTHER, 68.01, 274.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2305,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 267.92,,CLAIM ADJUSTMENT 3, 131.69,OTHER, 30.91, 267.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2306,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 116.49,OTHER, 56.08, 143.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2307,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 256.74,,CLAIM ADJUSTMENT 3, 405.48,OTHER, 256.74, 597.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2308,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2309,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 256.74,,CLAIM ADJUSTMENT 3, 216.69,OTHER, 107.31, 256.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2310,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2311,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 456.98,,CLAIM ADJUSTMENT 3, 233.68,OTHER, 60.50, 456.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2312,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 158.67,OTHER, 92.29, 204.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2313,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 112.58,OTHER, 70.21, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2314,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 125.44,OTHER, 81.25, 180.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2315,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 114.17,OTHER, 51.67, 151.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2316,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 122.15,OTHER, 60.94, 143.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2317,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 138.81,OTHER, 86.20, 205.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2318,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 117.21,OTHER, 74.19, 164.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2319,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 258.26,OTHER, 90.53, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2320,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 287.58,OTHER, 115.70, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2321,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 334.39,OTHER, 155.88, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2322,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 1514.68,OTHER, 804.50, 2338.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2323,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 1306.30,OTHER, 595.28, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2324,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 925.64,OTHER, 268.49, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2325,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 389.69,OTHER, 87.88, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2326,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 427.24,OTHER, 120.12, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2327,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 457.59,OTHER, 146.17, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2328,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 732.74,OTHER, 102.89, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2329,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1168.49,OTHER, 299.85, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2330,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 300.44,OTHER, 126.74, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2331,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 495.14,OTHER, 178.41, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2332,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 534.75,OTHER, 212.41, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2333,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 572.81,OTHER, 245.09, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2334,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 541.95,OTHER, 218.59, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2335,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 578.99,OTHER, 250.39, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2336,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 1505.88,OTHER, 766.62, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2337,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 646.89,OTHER, 308.68, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2338,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1242.56,OTHER, 363.44, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2339,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 513.14,OTHER, 193.86, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2340,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 520.86,OTHER, 200.49, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2341,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 694.73,OTHER, 349.75, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2342,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 947.76,OTHER, 287.48, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2343,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1393.28,OTHER, 492.83, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2344,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 56.01,OTHER, 24.73, 76.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2345,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 185.53,OTHER, 86.20, 331.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2346,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 97.29,OTHER, 57.09, 126.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2347,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 97.14,OTHER, 56.97, 126.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2348,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 57.02,OTHER, 22.52, 86.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2349,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 372.97,OTHER, 189.00, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2350,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1446.78,OTHER, 538.75, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2351,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1121.68,OTHER, 259.66, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2352,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 383.22,,CLAIM ADJUSTMENT 3, 278.63,OTHER, 165.01, 383.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2353,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 383.22,,CLAIM ADJUSTMENT 3, 427.61,OTHER, 296.20, 675.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2354,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 237.66,OTHER, 143.26, 408.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2355,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 253.66,OTHER, 143.26, 440.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2356,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 272.17,OTHER, 143.26, 477.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2357,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 251.39,OTHER, 143.26, 436.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2358,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 261.55,OTHER, 143.26, 400.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2359,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 264.56,OTHER, 143.26, 462.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2360,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 306.35,OTHER, 204.98, 467.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2361,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 548.12,OTHER, 309.01, 833.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2362,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 132.82,,CLAIM ADJUSTMENT 3, 300.52,OTHER, 132.82, 482.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2363,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 132.82,,CLAIM ADJUSTMENT 3, 293.08,OTHER, 132.82, 524.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2364,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 1023.77,OTHER, 309.01, 1906.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2365,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 498.22,OTHER, 309.01, 738.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2366,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 435.32,,CLAIM ADJUSTMENT 3, 1703.49,OTHER, 435.32, 3210.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2367,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 435.32,,CLAIM ADJUSTMENT 3, 601.46,OTHER, 382.87, 849.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2368,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2347.12,,CLAIM ADJUSTMENT 3, 2228.68,OTHER, 1193.64, 2648.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2369,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 2329.49,OTHER, 1296.54, 2877.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2370,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 274.44,,CLAIM ADJUSTMENT 3, 163.86,OTHER, 56.52, 274.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2371,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 200.99,OTHER, 145.30, 331.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2372,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 93.03,OTHER, 53.43, 118.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2373,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 43.50,,CLAIM ADJUSTMENT 3, 22.22,OTHER, 5.74, 43.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2374,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 224.77,OTHER, 146.61, 325.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2375,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 451.07,,CLAIM ADJUSTMENT 3, 251.63,OTHER, 77.72, 451.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2376,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2427.54,,CLAIM ADJUSTMENT 3, 1148.36,OTHER, 241.56, 2427.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2377,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2427.54,,CLAIM ADJUSTMENT 3, 1534.16,OTHER, 572.76, 2427.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2378,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 232.01,OTHER, 122.32, 271.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2379,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 124.43,OTHER, 57.02, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2380,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 120.23,OTHER, 53.32, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2381,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 130.25,OTHER, 62.14, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2382,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 130.25,OTHER, 62.14, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2383,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 5204.99,OTHER, 2293.79, 8355.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2384,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 932.84,OTHER, 274.68, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2385,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 424.57,OTHER, 162.56, 774.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2386,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 334.89,OTHER, 162.56, 594.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2387,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 470.23,,CLAIM ADJUSTMENT 3, 675.88,OTHER, 470.23, 1131.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2388,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 499.77,OTHER, 162.56, 925.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2389,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 499.77,OTHER, 162.56, 925.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2390,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 207.69,OTHER, 148.80, 339.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2391,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 207.69,OTHER, 148.80, 339.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2392,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 103.34,,CLAIM ADJUSTMENT 3, 176.70,OTHER, 103.34, 305.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2393,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 188.66,,CLAIM ADJUSTMENT 3, 596.69,OTHER, 188.66, 1107.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2394,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 188.66,,CLAIM ADJUSTMENT 3, 596.69,OTHER, 188.66, 1107.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2395,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 544.52,,CLAIM ADJUSTMENT 3, 1089.64,OTHER, 544.52, 1926.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2396,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2397,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2398,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2399,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2400,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2401,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2402,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 20.38,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2403,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2404,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 331.58,,CLAIM ADJUSTMENT 3, 579.04,OTHER, 331.58, 1003.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2405,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1095.12,,CLAIM ADJUSTMENT 3, 1525.88,OTHER, 974.17, 2161.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2406,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2484.68,,CLAIM ADJUSTMENT 3, 4097.24,OTHER, 2484.68, 6115.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2407,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2985.38,,CLAIM ADJUSTMENT 3, 4480.28,OTHER, 2930.90, 6504.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2408,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1095.12,,CLAIM ADJUSTMENT 3, 813.44,OTHER, 362.55, 1095.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2409,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1095.12,,CLAIM ADJUSTMENT 3, 4090.68,OTHER, 1095.12, 7048.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2410,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.22,,CLAIM ADJUSTMENT 3, 124.21,OTHER, 26.22, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2411,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.22,,CLAIM ADJUSTMENT 3, 124.21,OTHER, 26.22, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2412,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2414.09,,CLAIM ADJUSTMENT 3, 1187.28,OTHER, 279.09, 2414.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2413,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1685.72,,CLAIM ADJUSTMENT 3, 803.17,OTHER, 172.67, 1685.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2414,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1685.72,,CLAIM ADJUSTMENT 3, 1733.21,OTHER, 971.08, 2155.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2415,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 1757.99,OTHER, 857.80, 2765.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2416,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 477.65,OTHER, 147.05, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2417,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 497.71,OTHER, 164.28, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2418,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 1514.68,OTHER, 857.80, 2302.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2419,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 2013.65,OTHER, 857.80, 3252.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2420,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 549.67,OTHER, 208.88, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2421,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 578.48,OTHER, 233.61, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2422,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2423,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2424,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 625.15,,CLAIM ADJUSTMENT 3, 718.33,OTHER, 501.48, 1142.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2425,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2426,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2666.24,,CLAIM ADJUSTMENT 3, 1780.93,OTHER, 711.42, 2666.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2427,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4593.88,,CLAIM ADJUSTMENT 3, 2411.76,OTHER, 661.96, 4593.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2428,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 566.36,,CLAIM ADJUSTMENT 3, 283.55,OTHER, 69.77, 566.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2429,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 566.36,,CLAIM ADJUSTMENT 3, 298.98,OTHER, 83.02, 566.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2430,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 906.71,,CLAIM ADJUSTMENT 3, 482.77,OTHER, 136.45, 906.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2431,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 603.90,OTHER, 244.65, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2432,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 652.77,OTHER, 286.60, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2433,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 754.11,OTHER, 373.59, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2434,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 716.04,OTHER, 340.92, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2435,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 701.64,OTHER, 328.55, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2436,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1148.80,,CLAIM ADJUSTMENT 3, 2366.55,OTHER, 1148.80, 3726.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2437,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1384.25,,CLAIM ADJUSTMENT 3, 623.49,OTHER, 110.84, 1384.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2438,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 198.06,,CLAIM ADJUSTMENT 3, 256.43,OTHER, 159.42, 353.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2439,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1384.25,,CLAIM ADJUSTMENT 3, 637.38,OTHER, 122.76, 1384.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2440,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2350.90,,CLAIM ADJUSTMENT 3, 982.61,OTHER, 122.76, 2350.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2441,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2085.61,,CLAIM ADJUSTMENT 3, 1507.20,OTHER, 654.45, 2085.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2442,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3410.78,,CLAIM ADJUSTMENT 3, 3143.54,OTHER, 1652.91, 3668.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2443,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4593.88,,CLAIM ADJUSTMENT 3, 2486.35,OTHER, 725.99, 4593.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2444,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4593.88,,CLAIM ADJUSTMENT 3, 2559.90,OTHER, 789.14, 4593.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2445,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2446,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 539.71,,CLAIM ADJUSTMENT 3, 1667.02,OTHER, 539.71, 2808.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2447,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3135.31,,CLAIM ADJUSTMENT 3, 1786.42,OTHER, 572.31, 3135.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2448,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5153.51,,CLAIM ADJUSTMENT 3, 3662.54,OTHER, 1564.15, 5153.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2449,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1963.90,,CLAIM ADJUSTMENT 3, 889.66,OTHER, 161.63, 1963.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2450,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 191.60,,CLAIM ADJUSTMENT 3, 242.39,OTHER, 173.27, 394.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2451,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 191.60,,CLAIM ADJUSTMENT 3, 242.39,OTHER, 173.27, 394.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2452,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2085.61,,CLAIM ADJUSTMENT 3, 2146.09,OTHER, 1202.92, 2669.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2453,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 377.59,,CLAIM ADJUSTMENT 3, 199.77,OTHER, 96.75, 377.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2454,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 657.86,,CLAIM ADJUSTMENT 3, 266.50,OTHER, 96.75, 657.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2455,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1965.95,,CLAIM ADJUSTMENT 3, 2146.91,OTHER, 1478.34, 3369.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2456,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1965.95,,CLAIM ADJUSTMENT 3, 2146.91,OTHER, 1478.34, 3369.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2457,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2458,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2459,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2460,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4781.78,,CLAIM ADJUSTMENT 3, 2579.17,OTHER, 748.07, 4781.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2461,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 146.68,,CLAIM ADJUSTMENT 3, 162.43,OTHER, 112.28, 255.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2462,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 146.68,,CLAIM ADJUSTMENT 3, 145.32,OTHER, 97.21, 221.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2463,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 191.60,,CLAIM ADJUSTMENT 3, 116.13,OTHER, 62.09, 191.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2464,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 76.24,OTHER, 51.17, 116.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2465,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 124.60,OTHER, 86.34, 208.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2466,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2467,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 62.55,OTHER, 36.98, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2468,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2469,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 99.80,OTHER, 58.91, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2470,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2471,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 161.46,OTHER, 113.20, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2472,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2473,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 62.55,OTHER, 36.98, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2474,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2475,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 171.96,OTHER, 122.45, 279.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2476,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2477,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 127.74,OTHER, 86.34, 215.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2478,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2479,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 189.58,OTHER, 137.97, 314.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2480,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2481,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 116.92,OTHER, 84.85, 193.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2482,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2483,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 299.54,OTHER, 138.19, 535.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2484,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2485,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 221.04,OTHER, 138.19, 377.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2486,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2487,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 177.44,OTHER, 127.28, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2488,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2489,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 71.21,OTHER, 44.60, 101.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2490,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2491,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 193.56,OTHER, 86.34, 347.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2492,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2493,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 223.50,OTHER, 86.34, 407.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2494,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1313.91,OTHER, 283.82, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2495,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1313.91,OTHER, 283.82, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2496,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2497,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2498,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1196.04,OTHER, 432.18, 2193.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2499,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1196.04,OTHER, 432.18, 2193.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2500,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2501,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2502,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1545.39,OTHER, 485.27, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2503,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1545.39,OTHER, 485.27, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2504,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2505,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2506,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.20,OTHER, 283.82, 1781.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2507,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2508,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 691.35,OTHER, 432.18, 1180.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2509,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2510,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 887.08,OTHER, 485.27, 1548.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2511,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2512,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 901.22,OTHER, 283.82, 1673.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2513,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 901.22,OTHER, 283.82, 1673.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2514,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2515,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2516,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1055.93,OTHER, 432.18, 1912.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2517,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1302.68,OTHER, 432.18, 2407.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2518,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2519,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2520,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 513.03,OTHER, 350.02, 797.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2521,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2522,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1290.59,OTHER, 283.82, 2454.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2523,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2524,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1374.81,OTHER, 432.18, 2552.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2525,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2526,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1265.96,OTHER, 485.27, 2308.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2527,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2528,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1076.14,OTHER, 495.38, 1923.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2529,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1076.14,OTHER, 495.38, 1923.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2530,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1076.14,OTHER, 495.38, 1923.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2531,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2532,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2533,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2534,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1270.81,OTHER, 495.38, 2313.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2535,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2536,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1681.52,OTHER, 779.04, 3002.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2537,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2538,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1224.87,OTHER, 508.57, 2215.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2539,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2540,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 1324.21,OTHER, 616.91, 2362.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2541,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 438.95,OTHER, 187.68, 616.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2542,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1532.99,OTHER, 779.04, 2704.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2543,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2544,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1233.59,OTHER, 508.57, 2232.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2545,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2546,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 1256.33,OTHER, 616.91, 2226.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2547,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 438.95,OTHER, 187.68, 616.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2548,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1461.09,OTHER, 779.04, 2560.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2549,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2550,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1413.66,OTHER, 508.57, 2594.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2551,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2552,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2181.19,OTHER, 779.04, 4005.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2553,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2181.19,OTHER, 779.04, 4005.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2554,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2555,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2556,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2557,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2558,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2559,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2560,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2561,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2562,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2563,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2564,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2565,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2566,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2567,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2568,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2569,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2570,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 242.05,OTHER, 86.34, 444.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2571,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 243.52,OTHER, 86.34, 447.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2572,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2573,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2574,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 214.14,OTHER, 138.19, 363.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2575,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 240.03,OTHER, 138.19, 415.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2576,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2577,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2578,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 248.87,OTHER, 138.19, 433.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2579,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2580,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 165.10,OTHER, 86.34, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2581,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2582,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 62.55,OTHER, 36.98, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2583,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2584,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1211.40,OTHER, 283.82, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2585,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1211.40,OTHER, 283.82, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2586,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1211.40,OTHER, 283.82, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2587,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2588,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2589,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1356.87,OTHER, 432.18, 2737.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2590,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1356.87,OTHER, 432.18, 2737.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2591,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2592,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1817.25,OTHER, 485.27, 3415.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2593,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2594,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 1171.85,OTHER, 117.71, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2595,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 1171.85,OTHER, 117.71, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2596,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 1171.85,OTHER, 117.71, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2597,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 209.22,OTHER, 117.71, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2598,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 209.22,OTHER, 117.71, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2599,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 209.22,OTHER, 117.71, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2600,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2601,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2602,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2603,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2604,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2605,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2606,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2607,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2608,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2609,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2610,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2611,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2612,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2613,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.01,OTHER, 86.34, 297.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2614,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.01,OTHER, 86.34, 297.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2615,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2616,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2617,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 247.65,OTHER, 138.19, 430.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2618,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2619,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 350.60,OTHER, 138.19, 637.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2620,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2621,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 382.63,OTHER, 138.19, 701.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2622,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2623,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 293.50,OTHER, 138.19, 522.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2624,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2625,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 265.86,OTHER, 138.19, 467.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2626,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2627,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 161.46,OTHER, 113.20, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2628,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2629,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 142.64,OTHER, 86.34, 245.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2630,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2631,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 63.06,OTHER, 36.98, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2632,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 163.44,OTHER, 113.20, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2633,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 96.05,OTHER, 37.54, 146.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2634,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 259.24,OTHER, 138.19, 454.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2635,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2636,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 166.91,OTHER, 118.00, 268.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2637,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2638,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 407.08,OTHER, 138.19, 750.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2639,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2640,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1459.38,OTHER, 283.82, 2793.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2641,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1459.38,OTHER, 283.82, 2793.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2642,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1459.38,OTHER, 283.82, 2793.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2643,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2644,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2645,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2646,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 664.89,OTHER, 483.75, 1102.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2647,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2648,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1649.11,OTHER, 283.82, 3173.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2649,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1649.11,OTHER, 283.82, 3173.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2650,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2651,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2652,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1665.51,OTHER, 432.18, 3136.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2653,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2654,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1439.18,OTHER, 283.82, 2752.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2655,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2656,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1652.58,OTHER, 432.18, 3110.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2657,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2658,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1580.48,OTHER, 485.27, 2940.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2659,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2660,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1712.29,OTHER, 508.57, 3193.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2661,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2662,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1894.78,OTHER, 508.57, 3559.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2663,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2664,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1677.93,OTHER, 508.57, 3124.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2665,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2666,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2119.80,OTHER, 779.04, 3881.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2667,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2668,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2539.54,OTHER, 779.04, 4724.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2669,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2670,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2390.20,OTHER, 779.04, 4424.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2671,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2672,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2673,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2674,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2675,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 236.81,OTHER, 138.19, 409.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2676,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2677,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 193.87,OTHER, 138.19, 323.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2678,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2679,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1261.16,OTHER, 283.82, 2395.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2680,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1261.16,OTHER, 283.82, 2395.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2681,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2682,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2683,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1256.10,OTHER, 432.18, 2314.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2684,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2685,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 894.65,OTHER, 485.27, 1563.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2686,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2687,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1751.53,OTHER, 508.57, 3272.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2688,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2689,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2629.35,OTHER, 779.04, 4904.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2690,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2691,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2692,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2693,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2694,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2695,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2696,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2697,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 164.19,OTHER, 86.34, 288.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2698,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2699,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 224.35,OTHER, 86.34, 408.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2700,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2701,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 208.71,OTHER, 86.34, 377.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2702,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 208.71,OTHER, 86.34, 377.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2703,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 215.71,OTHER, 86.34, 391.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2704,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2705,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2706,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2707,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 149.11,OTHER, 86.34, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2708,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 149.11,OTHER, 86.34, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2709,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 149.11,OTHER, 86.34, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2710,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2711,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2712,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2713,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 175.84,OTHER, 86.34, 311.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2714,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.06,OTHER, 86.34, 298.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2715,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.06,OTHER, 86.34, 298.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2716,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2717,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2718,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2719,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 235.06,OTHER, 138.19, 405.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2720,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 235.06,OTHER, 138.19, 405.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2721,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 240.36,OTHER, 138.19, 416.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2722,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2723,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2724,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2725,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 219.70,OTHER, 86.34, 399.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2726,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 214.45,OTHER, 86.34, 389.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2727,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 214.45,OTHER, 86.34, 389.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2728,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2729,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2730,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2731,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 206.56,OTHER, 86.34, 373.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2732,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 211.81,OTHER, 86.34, 383.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2733,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 206.56,OTHER, 86.34, 373.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2734,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2735,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2736,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2737,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 230.04,OTHER, 86.34, 420.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2738,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 223.50,OTHER, 86.34, 407.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2739,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2740,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2741,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2742,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 230.83,OTHER, 86.34, 421.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2743,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 230.83,OTHER, 86.34, 421.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2744,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 237.37,OTHER, 86.34, 435.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2745,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2746,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2747,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2748,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 99.80,OTHER, 58.91, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2749,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 125.68,OTHER, 81.70, 186.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2750,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 99.80,OTHER, 58.91, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2751,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2752,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2753,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2754,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 213.73,OTHER, 86.34, 387.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2755,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 207.73,OTHER, 86.34, 375.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2756,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 207.74,OTHER, 86.34, 375.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2757,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2758,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2759,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2760,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 238.18,OTHER, 86.34, 436.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2761,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 243.44,OTHER, 86.34, 447.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2762,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 238.18,OTHER, 86.34, 436.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2763,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2764,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2765,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2766,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 238.48,OTHER, 138.19, 412.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2767,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 231.94,OTHER, 138.19, 399.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2768,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 231.94,OTHER, 138.19, 399.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2769,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2770,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2771,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2772,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 220.36,OTHER, 86.34, 400.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2773,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 220.42,OTHER, 86.34, 401.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2774,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 225.67,OTHER, 86.34, 411.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2775,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2776,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2777,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2778,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2779,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 174.69,OTHER, 86.34, 309.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2780,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2781,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2782,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2783,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2784,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2785,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2786,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2787,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2788,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2789,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2790,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2791,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2792,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2793,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2794,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2795,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2796,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2797,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2798,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2799,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2800,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2801,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2802,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2803,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2804,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2805,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1061.06,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2806,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2807,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2808,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2809,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2810,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2811,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2812,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2813,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2814,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2815,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2816,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2817,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2818,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2819,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2820,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2821,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2822,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2823,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2824,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2825,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2826,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2827,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2828,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2829,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2830,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2831,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2832,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2833,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1484.34,OTHER, 432.18, 2772.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2834,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1484.34,OTHER, 432.18, 2772.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2835,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2836,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2837,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2838,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2839,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2840,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2841,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2842,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1055.55,OTHER, 508.57, 1875.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2843,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2844,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1797.05,OTHER, 779.04, 3234.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2845,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1797.05,OTHER, 779.04, 3234.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2846,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1797.05,OTHER, 779.04, 3234.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2847,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2848,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2849,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2850,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2851,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2852,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2853,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2854,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2855,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2856,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2857,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2858,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2859,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2860,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2861,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2862,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2863,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2864,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2865,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2866,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2867,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2868,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2869,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2870,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2871,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2872,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2873,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2874,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2875,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2876,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2877,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2878,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2879,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2880,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2881,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2882,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1450.34,OTHER, 779.04, 2538.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2883,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1450.34,OTHER, 779.04, 2538.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2884,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2885,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2886,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2887,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2888,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2889,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 2890,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 196.99,OTHER, 88.46, 353.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2891,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 196.99,OTHER, 88.46, 353.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2892,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 196.99,OTHER, 88.46, 353.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2893,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2894,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2895,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2896,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2897,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2898,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2899,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2900,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2901,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2902,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2903,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2904,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2905,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 234.40,OTHER, 146.51, 446.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2906,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 234.40,OTHER, 146.51, 446.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2907,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 96.05,OTHER, 37.54, 146.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2908,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 96.05,OTHER, 37.54, 146.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2909,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 202.98,OTHER, 88.46, 365.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2910,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 202.98,OTHER, 88.46, 365.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2911,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 208.23,OTHER, 88.46, 375.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2912,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2913,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2914,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2915,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 210.73,OTHER, 86.34, 381.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2916,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 204.73,OTHER, 86.34, 369.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2917,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 204.73,OTHER, 86.34, 369.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2918,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2919,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2920,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2921,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 269.16,OTHER, 138.19, 474.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2922,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 274.41,OTHER, 138.19, 484.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2923,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 269.16,OTHER, 138.19, 474.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2924,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2925,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2926,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2927,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 402.07,OTHER, 138.19, 740.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2928,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 395.36,OTHER, 138.19, 727.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2929,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 395.36,OTHER, 138.19, 727.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2930,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2931,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2932,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2933,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 153.37,OTHER, 86.34, 266.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2934,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2935,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 243.07,OTHER, 86.34, 446.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2936,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 237.82,OTHER, 86.34, 436.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2937,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 237.82,OTHER, 86.34, 436.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2938,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2939,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2940,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2941,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 74.90,OTHER, 36.98, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2942,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 74.90,OTHER, 36.98, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2943,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 116.89,OTHER, 73.96, 168.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2944,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2945,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2946,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2947,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 218.95,OTHER, 138.19, 373.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2948,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 218.95,OTHER, 138.19, 373.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2949,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 225.30,OTHER, 138.19, 386.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2950,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2951,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2952,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2953,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 243.37,OTHER, 138.19, 422.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2954,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 236.76,OTHER, 138.19, 409.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2955,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 236.76,OTHER, 138.19, 409.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2956,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2957,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2958,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2959,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 186.56,OTHER, 86.34, 333.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2960,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 186.56,OTHER, 86.34, 333.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2961,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2962,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2963,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 250.19,OTHER, 86.34, 460.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2964,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 244.84,OTHER, 86.34, 450.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2965,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 244.94,OTHER, 86.34, 450.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2966,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2967,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2968,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2969,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 134.33,OTHER, 86.34, 228.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2970,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 134.33,OTHER, 86.34, 228.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2971,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 134.33,OTHER, 86.34, 228.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2972,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2973,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2974,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2975,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2976,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2977,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2978,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2979,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2980,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2981,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2982,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2983,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 179.26,OTHER, 86.34, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2984,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2985,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2986,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2987,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2988,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2989,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2990,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2991,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2992,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2993,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2994,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2995,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2996,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2997,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2998,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 2999,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3000,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1193.14,OTHER, 283.82, 2258.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3001,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3002,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3003,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3004,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3005,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3006,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3007,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3008,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3009,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3010,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3011,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3012,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3013,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3014,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3015,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3016,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3017,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3018,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3019,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3020,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3021,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3022,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3023,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3024,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3025,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1435.02,OTHER, 432.18, 2673.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3026,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1428.39,OTHER, 432.18, 2660.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3027,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1428.39,OTHER, 432.18, 2660.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3028,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3029,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3030,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3031,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3032,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3033,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3034,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3035,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3036,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3037,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 796.22,OTHER, 495.38, 1361.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3038,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 796.22,OTHER, 495.38, 1361.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3039,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3040,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3041,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3042,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3043,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3044,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3045,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3046,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3047,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3048,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3049,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3050,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3051,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3052,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3053,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1953.37,OTHER, 779.04, 3547.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3054,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1953.37,OTHER, 779.04, 3547.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3055,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3056,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3057,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3058,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3059,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3060,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3061,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3062,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3063,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3064,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3065,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3066,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3067,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3068,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3069,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3070,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3071,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3072,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3073,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3074,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3075,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3076,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3077,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3078,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3079,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3080,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3081,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3082,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3083,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3084,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3085,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3086,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3087,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3088,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3089,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3090,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3091,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3092,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3093,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3094,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3095,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3096,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3097,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 102.58,OTHER, 71.38, 162.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3098,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 102.58,OTHER, 71.38, 162.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3099,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3100,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3101,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 172.76,,CLAIM ADJUSTMENT 3, 83.13,OTHER, 36.98, 172.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3102,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 172.76,,CLAIM ADJUSTMENT 3, 105.42,OTHER, 37.54, 172.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3103,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 322.43,OTHER, 138.19, 581.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3104,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 322.43,OTHER, 138.19, 581.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3105,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3106,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3107,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1346.03,OTHER, 283.82, 2565.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3108,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3109,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1544.22,OTHER, 432.18, 2892.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3110,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3111,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1743.20,OTHER, 485.27, 3266.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3112,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3113,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 813.20,,CLAIM ADJUSTMENT 3, 3113.75,OTHER, 813.20, 5860.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3114,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 813.20,,CLAIM ADJUSTMENT 3, 473.04,OTHER, 156.77, 813.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3115,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1743.46,OTHER, 495.38, 3262.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3116,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3117,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 2609.45,OTHER, 276.02, 5105.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3118,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 2609.45,OTHER, 276.02, 5105.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3119,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 265.76,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3120,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 265.76,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3121,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 3021.78,OTHER, 426.91, 5860.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3122,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 3021.78,OTHER, 426.91, 5860.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3123,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 319.65,OTHER, 143.52, 426.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3124,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 319.65,OTHER, 143.52, 426.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3125,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 3385.13,OTHER, 475.94, 6566.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3126,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 3385.13,OTHER, 475.94, 6566.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3127,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 3385.13,OTHER, 475.94, 6566.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3128,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 337.16,OTHER, 143.52, 475.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3129,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 337.16,OTHER, 143.52, 475.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3130,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 337.16,OTHER, 143.52, 475.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3131,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1689.68,OTHER, 508.57, 3148.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3132,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1689.68,OTHER, 508.57, 3148.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3133,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3134,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3135,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1837.06,OTHER, 779.04, 3314.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3136,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3137,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3138,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3139,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3140,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3141,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3142,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 371.17,OTHER, 127.36, 684.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3143,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 371.17,OTHER, 127.36, 684.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3144,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 371.17,OTHER, 127.36, 684.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3145,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 89.21,OTHER, 37.54, 127.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3146,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 89.21,OTHER, 37.54, 127.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3147,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3148,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3149,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 248.14,OTHER, 166.15, 378.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3150,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 230.64,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3151,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 429.88,OTHER, 249.71, 743.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3152,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 132.91,OTHER, 37.54, 249.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3153,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1495.57,OTHER, 495.38, 2764.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3154,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1495.57,OTHER, 495.38, 2764.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3155,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3156,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3157,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3158,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3159,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 385.53,OTHER, 141.55, 706.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3160,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 385.53,OTHER, 141.55, 706.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3161,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 385.53,OTHER, 141.55, 706.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3162,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3163,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3164,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3165,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 286.59,OTHER, 90.89, 531.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3166,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3167,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 281.44,OTHER, 133.37, 501.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3168,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 281.44,OTHER, 133.37, 501.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3169,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 281.44,OTHER, 133.37, 501.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3170,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 288.12,OTHER, 133.37, 514.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3171,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3172,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3173,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3174,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3175,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 503.49,OTHER, 141.55, 942.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3176,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3177,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3178,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3179,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3180,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3181,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3182,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3183,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3184,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3185,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3186,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3187,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 163.97,,CLAIM ADJUSTMENT 3, 468.07,OTHER, 163.97, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3188,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 163.97,,CLAIM ADJUSTMENT 3, 200.02,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3189,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3190,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3191,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3192,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3193,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3194,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3195,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3196,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3197,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3198,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3199,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 414.50,OTHER, 141.55, 764.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3200,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3201,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 214.87,OTHER, 133.37, 367.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3202,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 163.37,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3203,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 408.73,OTHER, 141.55, 752.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3204,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3205,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 507.55,OTHER, 141.55, 950.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3206,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3207,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 775.60,OTHER, 90.89, 1513.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3208,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3209,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 290.56,OTHER, 133.37, 519.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3210,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3211,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.77,OTHER, 141.55, 774.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3212,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3213,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 471.58,OTHER, 141.55, 878.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3214,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 471.58,OTHER, 141.55, 878.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3215,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 471.58,OTHER, 141.55, 878.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3216,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3217,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3218,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3219,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 322.12,OTHER, 90.89, 613.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3220,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 322.12,OTHER, 90.89, 613.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3221,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3222,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3223,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 408.48,OTHER, 141.55, 752.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3224,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3225,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 813.95,OTHER, 137.10, 1568.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3226,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 526.64,OTHER, 137.10, 991.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3227,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 526.64,OTHER, 137.10, 991.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3228,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 190.42,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3229,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 190.42,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3230,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 190.42,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3231,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3232,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 300.33,OTHER, 133.37, 539.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3233,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3234,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3235,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3236,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3237,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3238,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3239,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3240,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3241,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3242,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3243,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3244,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3245,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3246,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3247,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3248,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3249,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3250,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3251,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3252,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3253,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3254,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3255,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3256,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3257,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3258,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3259,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3260,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3261,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 34.54,,CLAIM ADJUSTMENT 3, 78.82,OTHER, 21.15, 181.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3262,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3263,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3264,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3265,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3266,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3267,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3268,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3269,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3270,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 281.03,OTHER, 175.87, 480.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3271,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 281.03,OTHER, 175.87, 480.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3272,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 281.03,OTHER, 175.87, 480.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3273,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 198.15,OTHER, 99.36, 230.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3274,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 198.15,OTHER, 99.36, 230.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3275,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3276,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3277,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3278,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3279,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 235.21,OTHER, 81.44, 588.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3280,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 235.21,OTHER, 81.44, 588.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3281,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 235.21,OTHER, 81.44, 588.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3282,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3283,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3284,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3285,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3286,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3287,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3288,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3289,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 116.40,OTHER, 73.53, 167.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3290,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 70.96,OTHER, 18.55, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3291,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 232.03,,CLAIM ADJUSTMENT 3, 414.07,OTHER, 232.03, 720.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3292,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 158.67,OTHER, 84.28, 343.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3293,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 158.67,OTHER, 84.28, 343.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3294,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 59.28,OTHER, 18.55, 105.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3295,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 59.28,OTHER, 18.55, 105.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3296,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 42.36,,CLAIM ADJUSTMENT 3, 154.63,OTHER, 42.36, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3297,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 204.30,OTHER, 138.19, 343.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3298,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 70.96,OTHER, 18.55, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3299,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 660.83,OTHER, 156.82, 1251.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3300,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 660.83,OTHER, 156.82, 1251.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3301,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 171.75,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3302,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 171.75,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3303,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 533.81,OTHER, 206.35, 972.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3304,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 533.81,OTHER, 206.35, 972.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3305,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 189.44,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3306,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 189.44,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3307,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 320.35,,CLAIM ADJUSTMENT 3, 757.92,OTHER, 320.35, 1367.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3308,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 320.35,,CLAIM ADJUSTMENT 3, 230.15,OTHER, 99.36, 320.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3309,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 322.62,,CLAIM ADJUSTMENT 3, 899.81,OTHER, 322.62, 1651.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3310,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 322.62,,CLAIM ADJUSTMENT 3, 230.96,OTHER, 99.36, 322.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3311,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 548.80,,CLAIM ADJUSTMENT 3, 1092.65,OTHER, 548.80, 1930.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3312,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 548.80,,CLAIM ADJUSTMENT 3, 311.74,OTHER, 99.36, 548.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3313,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 864.03,OTHER, 423.08, 1531.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3314,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 266.84,OTHER, 99.36, 423.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3315,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 344.89,OTHER, 215.00, 490.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3316,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 266.84,OTHER, 99.36, 423.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3317,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 830.31,OTHER, 410.92, 1470.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3318,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 262.50,OTHER, 99.36, 410.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3319,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 1103.77,OTHER, 410.92, 2018.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3320,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 262.50,OTHER, 99.36, 410.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3321,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 1111.16,OTHER, 359.95, 2058.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3322,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 244.29,OTHER, 99.36, 359.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3323,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 624.07,OTHER, 359.95, 1080.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3324,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 244.29,OTHER, 99.36, 359.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3325,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 672.34,OTHER, 360.01, 1177.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3326,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3327,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 559.38,OTHER, 360.01, 950.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3328,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3329,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 1228.06,OTHER, 360.01, 2292.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3330,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3331,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 1294.05,OTHER, 360.01, 2425.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3332,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3333,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3334,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3335,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 1149.19,OTHER, 775.51, 1767.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3336,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 1149.19,OTHER, 775.51, 1767.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3337,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 518.51,OTHER, 99.36, 1127.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3338,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 518.51,OTHER, 99.36, 1127.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3339,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 2267.81,OTHER, 1127.76, 4012.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3340,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 518.51,OTHER, 99.36, 1127.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3341,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 815.01,OTHER, 444.92, 1423.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3342,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 815.01,OTHER, 444.92, 1423.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3343,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 274.64,OTHER, 99.36, 444.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3344,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 274.64,OTHER, 99.36, 444.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3345,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.54,,CLAIM ADJUSTMENT 3, 635.79,OTHER, 283.54, 1140.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3346,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.54,,CLAIM ADJUSTMENT 3, 217.00,OTHER, 99.36, 283.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3347,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 300.36,,CLAIM ADJUSTMENT 3, 984.09,OTHER, 300.36, 1831.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3348,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 300.36,,CLAIM ADJUSTMENT 3, 223.01,OTHER, 99.36, 300.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3349,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 443.12,,CLAIM ADJUSTMENT 3, 1050.06,OTHER, 443.12, 1895.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3350,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 443.12,,CLAIM ADJUSTMENT 3, 274.00,OTHER, 99.36, 443.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3351,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 742.64,,CLAIM ADJUSTMENT 3, 684.67,OTHER, 447.20, 1019.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3352,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 742.64,,CLAIM ADJUSTMENT 3, 380.97,OTHER, 99.36, 742.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3353,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 2685.69,OTHER, 1509.32, 4668.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3354,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 744.80,OTHER, 176.64, 1509.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3355,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 2768.70,OTHER, 1509.32, 4835.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3356,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 744.80,OTHER, 176.64, 1509.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3357,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.78,,CLAIM ADJUSTMENT 3, 34.30,OTHER, 19.78, 59.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3358,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.18,,CLAIM ADJUSTMENT 3, 32.49,OTHER, 12.18, 59.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3359,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3360,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 10.09,,CLAIM ADJUSTMENT 3, 70.69,OTHER, 10.09, 137.05,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3361,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 15.20,,CLAIM ADJUSTMENT 3, 122.16,OTHER, 15.20, 237.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3362,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.28,,CLAIM ADJUSTMENT 3, 97.60,OTHER, 19.28, 186.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3363,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.28,,CLAIM ADJUSTMENT 3, 97.60,OTHER, 19.28, 186.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3364,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.50,,CLAIM ADJUSTMENT 3, 83.55,OTHER, 12.50, 161.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3365,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.50,,CLAIM ADJUSTMENT 3, 83.55,OTHER, 12.50, 161.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3366,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 68.59,,CLAIM ADJUSTMENT 3, 155.85,OTHER, 68.59, 280.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3367,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.76,,CLAIM ADJUSTMENT 3, 78.98,OTHER, 11.76, 152.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3368,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 22.37,,CLAIM ADJUSTMENT 3, 69.30,OTHER, 22.37, 128.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3369,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.28,,CLAIM ADJUSTMENT 3, 229.30,OTHER, 46.28, 438.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3370,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 88.95,OTHER, 20.98, 172.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3371,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 88.95,OTHER, 20.98, 172.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3372,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.13,,CLAIM ADJUSTMENT 3, 53.39,OTHER, 19.13, 98.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3373,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.13,,CLAIM ADJUSTMENT 3, 53.39,OTHER, 19.13, 98.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3374,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.50,,CLAIM ADJUSTMENT 3, 80.17,OTHER, 19.50, 151.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3375,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 31.20,,CLAIM ADJUSTMENT 3, 54.61,OTHER, 31.20, 94.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3376,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 80.03,OTHER, 19.08, 151.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3377,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 79.17,OTHER, 19.08, 149.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3378,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.52,,CLAIM ADJUSTMENT 3, 63.95,OTHER, 9.52, 123.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3379,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 22.37,,CLAIM ADJUSTMENT 3, 28.28,OTHER, 20.21, 46.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3380,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 83.69,OTHER, 19.08, 158.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3381,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 22.03,,CLAIM ADJUSTMENT 3, 53.47,OTHER, 22.03, 96.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3382,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 79.81,OTHER, 19.08, 151.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3383,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.78,,CLAIM ADJUSTMENT 3, 44.64,OTHER, 19.78, 80.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3384,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.78,,CLAIM ADJUSTMENT 3, 145.91,OTHER, 19.78, 283.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3385,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.36,,CLAIM ADJUSTMENT 3, 64.76,OTHER, 20.36, 120.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3386,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.16,,CLAIM ADJUSTMENT 3, 121.34,OTHER, 17.16, 235.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3387,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.50,,CLAIM ADJUSTMENT 3, 84.76,OTHER, 19.50, 160.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3388,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 32.53,,CLAIM ADJUSTMENT 3, 134.69,OTHER, 32.53, 254.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3389,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.84,,CLAIM ADJUSTMENT 3, 90.91,OTHER, 26.84, 169.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3390,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 56.90,OTHER, 10.75, 186.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3391,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 56.90,OTHER, 10.75, 186.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3392,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 23.85,OTHER, 17.20, 39.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3393,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 23.85,OTHER, 17.20, 39.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3394,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3395,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3396,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3397,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3398,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3399,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3400,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3401,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3402,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3403,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3404,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3405,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3406,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3407,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3408,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3409,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3410,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3411,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3412,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3413,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.56,,CLAIM ADJUSTMENT 3, 34.88,OTHER, 4.56, 67.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3414,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.56,,CLAIM ADJUSTMENT 3, 34.88,OTHER, 4.56, 67.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3415,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.56,,CLAIM ADJUSTMENT 3, 34.88,OTHER, 4.56, 67.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3416,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 20.93,OTHER, 3.24, 40.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3417,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 20.93,OTHER, 3.24, 40.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3418,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 20.93,OTHER, 3.24, 40.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3419,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 7.12,OTHER, 3.24, 12.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3420,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.12,,CLAIM ADJUSTMENT 3, 8.07,OTHER, 3.12, 14.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3421,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 33.86,OTHER, 12.40, 62.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3422,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 33.86,OTHER, 12.40, 62.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3423,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 75.71,OTHER, 12.40, 146.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3424,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 75.71,OTHER, 12.40, 146.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3425,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.66,,CLAIM ADJUSTMENT 3, 145.60,OTHER, 105.66, 241.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3426,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.66,,CLAIM ADJUSTMENT 3, 145.60,OTHER, 105.66, 241.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3427,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 94.12,,CLAIM ADJUSTMENT 3, 262.66,OTHER, 94.12, 482.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3428,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 131.99,,CLAIM ADJUSTMENT 3, 428.98,OTHER, 131.99, 797.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3429,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3430,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3431,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3432,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.50,,CLAIM ADJUSTMENT 3, 53.15,OTHER, 6.50, 103.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3433,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.76,,CLAIM ADJUSTMENT 3, 38.90,OTHER, 11.76, 72.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3434,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 55.61,,CLAIM ADJUSTMENT 3, 146.83,OTHER, 55.61, 268.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3435,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.13,,CLAIM ADJUSTMENT 3, 20.13,OTHER, 7.13, 37.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3436,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.13,,CLAIM ADJUSTMENT 3, 20.13,OTHER, 7.13, 37.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3437,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.21,,CLAIM ADJUSTMENT 3, 28.92,OTHER, 11.21, 52.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3438,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.21,,CLAIM ADJUSTMENT 3, 28.92,OTHER, 11.21, 52.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3439,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.33,,CLAIM ADJUSTMENT 3, 60.58,OTHER, 8.33, 117.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3440,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.33,,CLAIM ADJUSTMENT 3, 60.58,OTHER, 8.33, 117.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3441,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 50.88,OTHER, 13.98, 95.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3442,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.36,,CLAIM ADJUSTMENT 3, 71.06,OTHER, 19.36, 133.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3443,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.82,,CLAIM ADJUSTMENT 3, 109.86,OTHER, 20.82, 210.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3444,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.14,,CLAIM ADJUSTMENT 3, 80.16,OTHER, 24.14, 149.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3445,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.14,,CLAIM ADJUSTMENT 3, 80.16,OTHER, 24.14, 149.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3446,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 63.10,OTHER, 20.98, 116.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3447,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 63.10,OTHER, 20.98, 116.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3448,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.34,,CLAIM ADJUSTMENT 3, 50.79,OTHER, 9.34, 97.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3449,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.34,,CLAIM ADJUSTMENT 3, 50.79,OTHER, 9.34, 97.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3450,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 42.16,,CLAIM ADJUSTMENT 3, 100.38,OTHER, 42.16, 181.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3451,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.34,,CLAIM ADJUSTMENT 3, 121.92,OTHER, 46.34, 222.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3452,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.37,,CLAIM ADJUSTMENT 3, 50.20,OTHER, 30.37, 86.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3453,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.31,,CLAIM ADJUSTMENT 3, 116.31,OTHER, 27.31, 220.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3454,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.24,,CLAIM ADJUSTMENT 3, 49.78,OTHER, 14.24, 93.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3455,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.30,,CLAIM ADJUSTMENT 3, 63.44,OTHER, 23.30, 116.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3456,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.22,,CLAIM ADJUSTMENT 3, 36.36,OTHER, 7.22, 69.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3457,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.22,,CLAIM ADJUSTMENT 3, 36.36,OTHER, 7.22, 69.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3458,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.22,,CLAIM ADJUSTMENT 3, 33.07,OTHER, 7.22, 62.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3459,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.31,,CLAIM ADJUSTMENT 3, 19.33,OTHER, 6.31, 35.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3460,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.38,,CLAIM ADJUSTMENT 3, 33.34,OTHER, 6.38, 63.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3461,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 22.92,,CLAIM ADJUSTMENT 3, 56.73,OTHER, 22.92, 102.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3462,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 42.62,,CLAIM ADJUSTMENT 3, 126.67,OTHER, 42.62, 244.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3463,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 42.62,,CLAIM ADJUSTMENT 3, 126.67,OTHER, 42.62, 244.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3464,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 42.62,,CLAIM ADJUSTMENT 3, 126.67,OTHER, 42.62, 244.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3465,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 38.58,,CLAIM ADJUSTMENT 3, 123.66,OTHER, 38.58, 229.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3466,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.43,,CLAIM ADJUSTMENT 3, 34.08,OTHER, 7.43, 64.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3467,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.43,,CLAIM ADJUSTMENT 3, 34.08,OTHER, 7.43, 64.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3468,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.43,,CLAIM ADJUSTMENT 3, 34.08,OTHER, 7.43, 64.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3469,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.70,,CLAIM ADJUSTMENT 3, 69.24,OTHER, 19.70, 129.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3470,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.69,,CLAIM ADJUSTMENT 3, 49.97,OTHER, 8.69, 96.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3471,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.58,,CLAIM ADJUSTMENT 3, 44.47,OTHER, 18.58, 80.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3472,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.74,,CLAIM ADJUSTMENT 3, 65.14,OTHER, 17.74, 122.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3473,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.30,,CLAIM ADJUSTMENT 3, 87.25,OTHER, 27.30, 162.05,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3474,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.30,,CLAIM ADJUSTMENT 3, 87.25,OTHER, 27.30, 162.05,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3475,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.29,,CLAIM ADJUSTMENT 3, 59.01,OTHER, 24.29, 106.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3476,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 36.36,,CLAIM ADJUSTMENT 3, 127.93,OTHER, 36.36, 240.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3477,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 36.36,,CLAIM ADJUSTMENT 3, 127.93,OTHER, 36.36, 240.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3478,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 56.46,OTHER, 15.47, 105.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3479,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.28,,CLAIM ADJUSTMENT 3, 13.69,OTHER, 8.28, 23.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3480,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.87,,CLAIM ADJUSTMENT 3, 73.71,OTHER, 17.87, 139.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3481,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.06,,CLAIM ADJUSTMENT 3, 87.73,OTHER, 24.06, 164.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3482,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.06,,CLAIM ADJUSTMENT 3, 87.73,OTHER, 24.06, 164.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3483,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.47,,CLAIM ADJUSTMENT 3, 66.31,OTHER, 23.47, 121.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3484,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.47,,CLAIM ADJUSTMENT 3, 66.31,OTHER, 23.47, 121.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3485,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 34.69,,CLAIM ADJUSTMENT 3, 190.19,OTHER, 34.69, 365.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3486,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 34.69,,CLAIM ADJUSTMENT 3, 214.01,OTHER, 34.69, 412.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3487,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.37,,CLAIM ADJUSTMENT 3, 47.49,OTHER, 9.37, 90.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3488,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.37,,CLAIM ADJUSTMENT 3, 47.49,OTHER, 9.37, 90.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3489,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.28,,CLAIM ADJUSTMENT 3, 41.70,OTHER, 19.28, 74.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3490,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.63,,CLAIM ADJUSTMENT 3, 59.73,OTHER, 16.63, 111.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3491,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.37,,CLAIM ADJUSTMENT 3, 31.62,OTHER, 7.37, 59.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3492,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.37,,CLAIM ADJUSTMENT 3, 31.62,OTHER, 7.37, 59.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3493,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.37,,CLAIM ADJUSTMENT 3, 31.62,OTHER, 7.37, 59.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3494,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 39.11,OTHER, 7.46, 74.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3495,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 39.11,OTHER, 7.46, 74.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3496,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.62,,CLAIM ADJUSTMENT 3, 93.47,OTHER, 13.62, 181.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3497,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.62,,CLAIM ADJUSTMENT 3, 93.47,OTHER, 13.62, 181.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3498,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.97,,CLAIM ADJUSTMENT 3, 45.06,OTHER, 16.97, 82.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3499,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 76.21,OTHER, 9.31, 148.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3500,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.72,,CLAIM ADJUSTMENT 3, 72.23,OTHER, 21.72, 134.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3501,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.72,,CLAIM ADJUSTMENT 3, 72.23,OTHER, 21.72, 134.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3502,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 75.36,OTHER, 26.66, 138.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3503,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 75.36,OTHER, 26.66, 138.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3504,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 36.38,,CLAIM ADJUSTMENT 3, 127.42,OTHER, 36.38, 238.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3505,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 36.38,,CLAIM ADJUSTMENT 3, 127.42,OTHER, 36.38, 238.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3506,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.06,,CLAIM ADJUSTMENT 3, 93.87,OTHER, 27.06, 175.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3507,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 40.24,,CLAIM ADJUSTMENT 3, 135.49,OTHER, 40.24, 252.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3508,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 40.24,,CLAIM ADJUSTMENT 3, 135.49,OTHER, 40.24, 252.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3509,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.51,,CLAIM ADJUSTMENT 3, 83.83,OTHER, 46.51, 146.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3510,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 34.82,,CLAIM ADJUSTMENT 3, 73.72,OTHER, 34.82, 131.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3511,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 35.93,,CLAIM ADJUSTMENT 3, 75.45,OTHER, 35.93, 134.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3512,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 33.53,,CLAIM ADJUSTMENT 3, 121.64,OTHER, 33.53, 228.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3513,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.34,,CLAIM ADJUSTMENT 3, 69.17,OTHER, 7.34, 135.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3514,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.19,,CLAIM ADJUSTMENT 3, 124.67,OTHER, 24.19, 238.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3515,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.63,,CLAIM ADJUSTMENT 3, 76.46,OTHER, 19.63, 144.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3516,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.17,,CLAIM ADJUSTMENT 3, 71.48,OTHER, 21.17, 133.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3517,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3518,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3519,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3520,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3521,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3522,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.70,,CLAIM ADJUSTMENT 3, 64.96,OTHER, 23.70, 119.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3523,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.54,,CLAIM ADJUSTMENT 3, 34.98,OTHER, 11.54, 64.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3524,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.54,,CLAIM ADJUSTMENT 3, 203.52,OTHER, 37.54, 390.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3525,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.39,,CLAIM ADJUSTMENT 3, 61.71,OTHER, 25.39, 111.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3526,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 25.64,OTHER, 5.66, 48.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3527,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 25.64,OTHER, 5.66, 48.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3528,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 25.64,OTHER, 5.66, 48.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3529,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 28.32,OTHER, 5.66, 54.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3530,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 28.32,OTHER, 5.66, 54.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3531,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 28.32,OTHER, 5.66, 54.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3532,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 14.14,OTHER, 5.66, 25.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3533,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 64.46,OTHER, 6.84, 126.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3534,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 64.46,OTHER, 6.84, 126.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3535,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.97,,CLAIM ADJUSTMENT 3, 57.91,OTHER, 13.97, 109.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3536,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 10.37,,CLAIM ADJUSTMENT 3, 37.55,OTHER, 10.37, 70.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3537,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.76,,CLAIM ADJUSTMENT 3, 94.73,OTHER, 26.76, 177.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3538,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.76,,CLAIM ADJUSTMENT 3, 94.73,OTHER, 26.76, 177.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3539,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 94.52,OTHER, 26.66, 176.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3540,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 94.52,OTHER, 26.66, 176.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3541,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.12,,CLAIM ADJUSTMENT 3, 67.05,OTHER, 18.12, 125.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3542,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 31.62,,CLAIM ADJUSTMENT 3, 74.92,OTHER, 31.62, 135.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3543,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 48.30,OTHER, 13.98, 90.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3544,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 48.30,OTHER, 13.98, 90.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3545,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 48.30,OTHER, 13.98, 90.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3546,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.80,,CLAIM ADJUSTMENT 3, 99.83,OTHER, 25.80, 188.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3547,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3548,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3549,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3550,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3551,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3552,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3553,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.86,,CLAIM ADJUSTMENT 3, 128.28,OTHER, 24.86, 290.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3554,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.86,,CLAIM ADJUSTMENT 3, 128.28,OTHER, 24.86, 290.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3555,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.86,,CLAIM ADJUSTMENT 3, 128.28,OTHER, 24.86, 290.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3556,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 25.93,OTHER, 18.49, 42.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3557,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.46,,CLAIM ADJUSTMENT 3, 69.04,OTHER, 16.46, 130.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3558,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 43.88,OTHER, 9.31, 83.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3559,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 43.88,OTHER, 9.31, 83.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3560,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 43.88,OTHER, 9.31, 83.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3561,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3562,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3563,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3564,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3565,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.66,,CLAIM ADJUSTMENT 3, 70.04,OTHER, 16.66, 132.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3566,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.70,,CLAIM ADJUSTMENT 3, 51.00,OTHER, 8.70, 111.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3567,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.70,,CLAIM ADJUSTMENT 3, 51.00,OTHER, 8.70, 111.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3568,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.42,,CLAIM ADJUSTMENT 3, 85.45,OTHER, 18.42, 162.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3569,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 28.37,,CLAIM ADJUSTMENT 3, 68.77,OTHER, 28.37, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3570,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.44,,CLAIM ADJUSTMENT 3, 54.77,OTHER, 17.44, 101.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3571,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.44,,CLAIM ADJUSTMENT 3, 54.77,OTHER, 17.44, 101.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3572,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.92,,CLAIM ADJUSTMENT 3, 60.48,OTHER, 9.92, 116.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3573,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.92,,CLAIM ADJUSTMENT 3, 60.48,OTHER, 9.92, 116.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3574,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 66.68,,CLAIM ADJUSTMENT 3, 149.05,OTHER, 66.68, 267.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3575,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 49.24,,CLAIM ADJUSTMENT 3, 43.46,OTHER, 27.95, 63.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3576,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 15.12,,CLAIM ADJUSTMENT 3, 43.01,OTHER, 15.12, 79.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3577,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 15.12,,CLAIM ADJUSTMENT 3, 43.01,OTHER, 15.12, 79.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3578,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.65,,CLAIM ADJUSTMENT 3, 40.64,OTHER, 9.65, 76.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3579,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 34.72,,CLAIM ADJUSTMENT 3, 204.04,OTHER, 34.72, 392.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3580,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.41,,CLAIM ADJUSTMENT 3, 57.49,OTHER, 23.41, 104.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3581,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 159.56,OTHER, 24.40, 308.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3582,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 159.56,OTHER, 24.40, 308.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3583,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.60,,CLAIM ADJUSTMENT 3, 74.79,OTHER, 18.60, 163.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3584,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.60,,CLAIM ADJUSTMENT 3, 74.79,OTHER, 18.60, 163.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3585,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 56.53,,CLAIM ADJUSTMENT 3, 120.40,OTHER, 56.53, 214.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3586,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 56.53,,CLAIM ADJUSTMENT 3, 120.40,OTHER, 56.53, 214.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3587,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.54,,CLAIM ADJUSTMENT 3, 110.95,OTHER, 30.54, 208.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3588,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.52,,CLAIM ADJUSTMENT 3, 54.17,OTHER, 9.52, 104.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3589,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.82,,CLAIM ADJUSTMENT 3, 44.45,OTHER, 9.82, 84.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3590,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.82,,CLAIM ADJUSTMENT 3, 44.45,OTHER, 9.82, 84.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3591,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.81,,CLAIM ADJUSTMENT 3, 86.15,OTHER, 20.81, 162.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3592,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 59.45,,CLAIM ADJUSTMENT 3, 147.00,OTHER, 59.45, 266.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3593,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 59.45,,CLAIM ADJUSTMENT 3, 147.00,OTHER, 59.45, 266.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3594,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.89,,CLAIM ADJUSTMENT 3, 43.75,OTHER, 27.89, 74.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3595,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 28.27,,CLAIM ADJUSTMENT 3, 186.61,OTHER, 28.27, 361.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3596,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 45.87,OTHER, 7.46, 92.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3597,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 45.87,OTHER, 7.46, 92.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3598,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.83,,CLAIM ADJUSTMENT 3, 35.19,OTHER, 6.83, 67.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3599,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.83,,CLAIM ADJUSTMENT 3, 35.19,OTHER, 6.83, 67.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3600,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.85,,CLAIM ADJUSTMENT 3, 28.87,OTHER, 6.85, 54.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3601,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.82,,CLAIM ADJUSTMENT 3, 13.83,OTHER, 6.82, 24.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3602,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.01,,CLAIM ADJUSTMENT 3, 45.56,OTHER, 21.01, 81.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3603,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.04,,CLAIM ADJUSTMENT 3, 92.72,OTHER, 30.04, 171.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3604,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.04,,CLAIM ADJUSTMENT 3, 92.72,OTHER, 30.04, 171.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3605,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 39.19,,CLAIM ADJUSTMENT 3, 102.79,OTHER, 39.19, 187.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3606,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.91,,CLAIM ADJUSTMENT 3, 97.17,OTHER, 27.91, 181.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3607,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.48,,CLAIM ADJUSTMENT 3, 90.21,OTHER, 26.48, 174.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3608,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.48,,CLAIM ADJUSTMENT 3, 90.21,OTHER, 26.48, 174.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3609,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.48,,CLAIM ADJUSTMENT 3, 93.39,OTHER, 26.48, 174.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3610,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 24.66,OTHER, 5.28, 46.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3611,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 24.66,OTHER, 5.28, 46.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3612,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 57.84,OTHER, 5.28, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3613,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 57.84,OTHER, 5.28, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3614,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 57.84,OTHER, 5.28, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3615,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.76,,CLAIM ADJUSTMENT 3, 41.90,OTHER, 5.76, 83.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3616,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.76,,CLAIM ADJUSTMENT 3, 41.90,OTHER, 5.76, 83.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3617,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.76,,CLAIM ADJUSTMENT 3, 41.90,OTHER, 5.76, 83.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3618,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 144.06,OTHER, 15.47, 390.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3619,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 144.06,OTHER, 15.47, 390.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3620,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.68,,CLAIM ADJUSTMENT 3, 141.59,OTHER, 25.68, 394.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3621,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.68,,CLAIM ADJUSTMENT 3, 141.59,OTHER, 25.68, 394.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3622,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 38.44,,CLAIM ADJUSTMENT 3, 136.35,OTHER, 38.44, 255.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3623,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 40.46,,CLAIM ADJUSTMENT 3, 103.27,OTHER, 40.46, 187.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3624,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 31.67,,CLAIM ADJUSTMENT 3, 76.88,OTHER, 31.67, 139.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3625,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.15,,CLAIM ADJUSTMENT 3, 178.83,OTHER, 29.15, 344.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3626,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 31.30,,CLAIM ADJUSTMENT 3, 88.43,OTHER, 31.30, 162.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3627,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.92,,CLAIM ADJUSTMENT 3, 30.02,OTHER, 6.92, 56.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3628,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.92,,CLAIM ADJUSTMENT 3, 30.02,OTHER, 6.92, 56.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3629,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.28,,CLAIM ADJUSTMENT 3, 34.17,OTHER, 7.28, 88.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3630,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.28,,CLAIM ADJUSTMENT 3, 34.17,OTHER, 7.28, 88.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3631,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.28,,CLAIM ADJUSTMENT 3, 34.17,OTHER, 7.28, 88.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3632,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.61,,CLAIM ADJUSTMENT 3, 180.72,OTHER, 30.61, 348.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3633,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.66,,CLAIM ADJUSTMENT 3, 302.95,OTHER, 11.66, 602.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3634,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 36.67,,CLAIM ADJUSTMENT 3, 81.90,OTHER, 36.67, 146.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3635,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3636,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3637,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3638,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3639,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.58,,CLAIM ADJUSTMENT 3, 86.80,OTHER, 30.58, 159.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3640,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.58,,CLAIM ADJUSTMENT 3, 86.80,OTHER, 30.58, 159.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3641,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.12,,CLAIM ADJUSTMENT 3, 107.35,OTHER, 23.12, 204.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3642,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.12,,CLAIM ADJUSTMENT 3, 107.35,OTHER, 23.12, 204.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3643,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.89,,CLAIM ADJUSTMENT 3, 53.27,OTHER, 9.89, 102.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3644,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.89,,CLAIM ADJUSTMENT 3, 53.27,OTHER, 9.89, 102.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3645,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.98,,CLAIM ADJUSTMENT 3, 75.95,OTHER, 12.98, 146.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3646,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.98,,CLAIM ADJUSTMENT 3, 75.95,OTHER, 12.98, 146.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3647,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.98,,CLAIM ADJUSTMENT 3, 75.95,OTHER, 12.98, 146.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3648,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.29,,CLAIM ADJUSTMENT 3, 51.95,OTHER, 21.29, 94.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3649,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.19,,CLAIM ADJUSTMENT 3, 73.53,OTHER, 24.19, 136.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3650,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 73.24,,CLAIM ADJUSTMENT 3, 154.17,OTHER, 73.24, 274.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3651,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 73.24,,CLAIM ADJUSTMENT 3, 154.17,OTHER, 73.24, 274.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3652,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.42,,CLAIM ADJUSTMENT 3, 49.79,OTHER, 20.42, 90.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3653,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 38.32,OTHER, 7.46, 73.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3654,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.63,,CLAIM ADJUSTMENT 3, 35.99,OTHER, 7.63, 68.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3655,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.37,,CLAIM ADJUSTMENT 3, 58.51,OTHER, 18.37, 108.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3656,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.27,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 8.27, 74.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3657,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.42,,CLAIM ADJUSTMENT 3, 79.41,OTHER, 20.42, 149.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3658,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.42,,CLAIM ADJUSTMENT 3, 79.41,OTHER, 20.42, 149.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3659,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 78.90,OTHER, 24.40, 146.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3660,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 78.90,OTHER, 24.40, 146.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3661,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 22.69,,CLAIM ADJUSTMENT 3, 126.89,OTHER, 22.69, 243.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3662,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.95,,CLAIM ADJUSTMENT 3, 82.99,OTHER, 17.95, 157.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3663,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.95,,CLAIM ADJUSTMENT 3, 82.99,OTHER, 17.95, 157.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3664,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.69,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 5.69, 75.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3665,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.69,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 5.69, 75.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3666,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.69,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 5.69, 75.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3667,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.00,,CLAIM ADJUSTMENT 3, 22.60,OTHER, 8.00, 41.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3668,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.00,,CLAIM ADJUSTMENT 3, 22.60,OTHER, 8.00, 41.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3669,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.50,,CLAIM ADJUSTMENT 3, 31.87,OTHER, 6.50, 60.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3670,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.32,,CLAIM ADJUSTMENT 3, 39.10,OTHER, 7.32, 74.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3671,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.72,,CLAIM ADJUSTMENT 3, 76.33,OTHER, 16.72, 145.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3672,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.75,,CLAIM ADJUSTMENT 3, 103.71,OTHER, 19.75, 198.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3673,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.40,,CLAIM ADJUSTMENT 3, 56.68,OTHER, 16.40, 105.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3674,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.40,,CLAIM ADJUSTMENT 3, 56.68,OTHER, 16.40, 105.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3675,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.40,,CLAIM ADJUSTMENT 3, 56.68,OTHER, 16.40, 105.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3676,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 29.96, 157.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3677,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.67,,CLAIM ADJUSTMENT 3, 97.04,OTHER, 21.67, 184.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3678,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.94,,CLAIM ADJUSTMENT 3, 42.88,OTHER, 6.94, 82.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3679,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.47,,CLAIM ADJUSTMENT 3, 43.80,OTHER, 5.47, 85.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3680,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 17.85,OTHER, 3.41, 34.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3681,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 17.85,OTHER, 3.41, 34.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3682,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 21.46,OTHER, 3.41, 41.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3683,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 21.46,OTHER, 3.41, 41.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3684,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 22.31,OTHER, .01, 84.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3685,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.18,,CLAIM ADJUSTMENT 3, 22.31,OTHER, .01, 84.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3686,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 44.71,OTHER, 9.31, 85.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3687,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.75,,CLAIM ADJUSTMENT 3, 37.65,OTHER, 5.75, 72.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3688,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.75,,CLAIM ADJUSTMENT 3, 37.65,OTHER, 5.75, 72.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3689,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.66,,CLAIM ADJUSTMENT 3, 19.92,OTHER, 3.66, 38.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3690,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.46,,CLAIM ADJUSTMENT 3, 32.63,OTHER, 6.46, 62.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3691,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.78,,CLAIM ADJUSTMENT 3, 96.77,OTHER, 25.78, 181.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3692,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 33.04,,CLAIM ADJUSTMENT 3, 129.31,OTHER, 33.04, 243.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3693,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.06,,CLAIM ADJUSTMENT 3, 130.54,OTHER, 17.06, 253.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3694,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.93,,CLAIM ADJUSTMENT 3, 98.34,OTHER, 19.93, 187.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3695,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 22.06,,CLAIM ADJUSTMENT 3, 89.00,OTHER, 22.06, 168.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3696,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.66,,CLAIM ADJUSTMENT 3, 98.22,OTHER, 14.66, 190.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3697,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.99,,CLAIM ADJUSTMENT 3, 54.63,OTHER, 13.99, 102.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3698,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.00,,CLAIM ADJUSTMENT 3, 70.40,OTHER, 27.00, 128.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3699,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 29.86,OTHER, 6.18, 57.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3700,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 29.86,OTHER, 6.18, 57.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3701,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 29.86,OTHER, 6.18, 57.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3702,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3703,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3704,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3705,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3706,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 41.60,OTHER, 6.14, 80.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3707,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.89,,CLAIM ADJUSTMENT 3, 26.32,OTHER, 3.89, 50.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3708,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.93,,CLAIM ADJUSTMENT 3, 36.35,OTHER, 7.93, 69.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3709,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.65,,CLAIM ADJUSTMENT 3, 61.85,OTHER, 8.65, 166.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3710,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.65,,CLAIM ADJUSTMENT 3, 61.85,OTHER, 8.65, 166.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3711,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.26,,CLAIM ADJUSTMENT 3, 76.67,OTHER, 11.26, 148.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3712,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3713,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3714,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3715,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3716,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3717,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3718,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3719,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3720,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3721,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3722,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3723,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3724,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3725,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3726,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3727,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3728,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3729,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3730,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3731,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3732,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3733,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3734,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3735,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3736,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3737,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3738,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3739,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3740,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3741,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3742,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3743,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3744,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3745,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3746,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3747,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3748,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3749,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3750,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3751,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3752,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3753,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3754,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3755,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3756,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3757,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3758,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3759,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3760,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3761,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3762,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3763,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3764,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3765,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3766,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3767,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3768,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3769,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3770,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3771,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3772,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3773,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3774,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.45,,CLAIM ADJUSTMENT 3, 189.29,OTHER, 26.45, 367.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3775,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.46,,CLAIM ADJUSTMENT 3, 115.17,OTHER, 14.46, 224.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3776,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.41,,CLAIM ADJUSTMENT 3, 91.70,OTHER, 17.41, 220.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3777,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.41,,CLAIM ADJUSTMENT 3, 91.70,OTHER, 17.41, 220.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3778,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.07,,CLAIM ADJUSTMENT 3, 48.91,OTHER, 16.07, 90.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3779,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 10.51,,CLAIM ADJUSTMENT 3, 45.23,OTHER, 10.51, 85.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3780,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 17.08,OTHER, 7.46, 30.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3781,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 17.08,OTHER, 7.46, 30.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3782,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.65,,CLAIM ADJUSTMENT 3, 59.25,OTHER, 18.65, 110.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3783,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 36.65,,CLAIM ADJUSTMENT 3, 93.98,OTHER, 36.65, 171.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3784,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 36.65,,CLAIM ADJUSTMENT 3, 137.37,OTHER, 36.65, 258.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3785,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.14,,CLAIM ADJUSTMENT 3, 78.46,OTHER, 23.14, 146.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3786,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.28,,CLAIM ADJUSTMENT 3, 67.64,OTHER, 17.28, 127.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3787,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.28,,CLAIM ADJUSTMENT 3, 67.64,OTHER, 17.28, 127.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3788,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.26,,CLAIM ADJUSTMENT 3, 77.69,OTHER, 29.26, 141.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3789,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.65,,CLAIM ADJUSTMENT 3, 63.19,OTHER, 18.65, 117.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3790,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.79,,CLAIM ADJUSTMENT 3, 65.88,OTHER, 19.79, 127.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3791,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.79,,CLAIM ADJUSTMENT 3, 65.88,OTHER, 19.79, 127.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3792,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3793,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3794,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3795,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3796,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3797,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3798,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 68.02,OTHER, 17.35, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3799,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 68.02,OTHER, 17.35, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3800,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 68.02,OTHER, 17.35, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3801,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 120.82,OTHER, 17.35, 238.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3802,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 120.82,OTHER, 17.35, 238.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3803,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.46,,CLAIM ADJUSTMENT 3, 15.65,OTHER, 10.75, 24.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3804,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 80.94,OTHER, 29.96, 150.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3805,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 80.94,OTHER, 29.96, 150.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3806,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 85.12,OTHER, 29.96, 156.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3807,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 103.45,OTHER, 29.96, 193.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3808,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.97,,CLAIM ADJUSTMENT 3, 125.05,OTHER, 24.97, 345.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3809,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.97,,CLAIM ADJUSTMENT 3, 125.05,OTHER, 24.97, 345.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3810,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 50.54,OTHER, 7.46, 97.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3811,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 32.17,,CLAIM ADJUSTMENT 3, 88.87,OTHER, 32.17, 162.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3812,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.83,,CLAIM ADJUSTMENT 3, 66.43,OTHER, 30.83, 118.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3813,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.72,,CLAIM ADJUSTMENT 3, 57.43,OTHER, 21.72, 104.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3814,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 33.95,,CLAIM ADJUSTMENT 3, 265.06,OTHER, 33.95, 515.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3815,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 80.97,OTHER, 38.57, 144.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3816,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 80.97,OTHER, 38.57, 144.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3817,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 54.34,,CLAIM ADJUSTMENT 3, 111.82,OTHER, 54.34, 198.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3818,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 67.64,,CLAIM ADJUSTMENT 3, 176.22,OTHER, 67.64, 321.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3819,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 88.05,OTHER, 38.57, 158.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3820,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 88.05,OTHER, 38.57, 158.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3821,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.84,,CLAIM ADJUSTMENT 3, 68.73,OTHER, 13.84, 131.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3822,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.95,,CLAIM ADJUSTMENT 3, 96.09,OTHER, 20.95, 205.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3823,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.95,,CLAIM ADJUSTMENT 3, 96.09,OTHER, 20.95, 205.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3824,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.60,,CLAIM ADJUSTMENT 3, 70.10,OTHER, 19.60, 131.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3825,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.16,,CLAIM ADJUSTMENT 3, 46.86,OTHER, 8.16, 90.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3826,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.16,,CLAIM ADJUSTMENT 3, 46.86,OTHER, 8.16, 90.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3827,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 89.24,,CLAIM ADJUSTMENT 3, 191.67,OTHER, 89.24, 342.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3828,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.33,,CLAIM ADJUSTMENT 3, 12.31,OTHER, 8.04, 18.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3829,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.34,,CLAIM ADJUSTMENT 3, 18.56,OTHER, 6.34, 34.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3830,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.67,,CLAIM ADJUSTMENT 3, 36.21,OTHER, 21.67, 62.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3831,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.66,,CLAIM ADJUSTMENT 3, 55.25,OTHER, 14.66, 103.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3832,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.58,,CLAIM ADJUSTMENT 3, 40.13,OTHER, 18.58, 71.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3833,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.00,,CLAIM ADJUSTMENT 3, 66.54,OTHER, 19.00, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3834,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.53,,CLAIM ADJUSTMENT 3, 88.38,OTHER, 24.53, 165.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3835,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.53,,CLAIM ADJUSTMENT 3, 88.38,OTHER, 24.53, 165.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3836,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.53,,CLAIM ADJUSTMENT 3, 88.38,OTHER, 24.53, 165.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3837,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.29,,CLAIM ADJUSTMENT 3, 26.75,OTHER, 17.29, 45.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3838,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.51,,CLAIM ADJUSTMENT 3, 91.08,OTHER, 16.51, 254.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3839,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.51,,CLAIM ADJUSTMENT 3, 91.08,OTHER, 16.51, 254.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3840,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 50.83,OTHER, 20.72, 92.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3841,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 59.00,OTHER, 24.26, 106.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3842,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 22.02,,CLAIM ADJUSTMENT 3, 64.46,OTHER, 22.02, 118.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3843,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.12,,CLAIM ADJUSTMENT 3, 59.50,OTHER, 26.12, 106.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3844,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.12,,CLAIM ADJUSTMENT 3, 59.50,OTHER, 26.12, 106.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3845,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 71.41,OTHER, 24.26, 179.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3846,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 71.41,OTHER, 24.26, 179.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3847,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 71.41,OTHER, 24.26, 179.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3848,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.86,,CLAIM ADJUSTMENT 3, 66.70,OTHER, 27.86, 120.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3849,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.86,,CLAIM ADJUSTMENT 3, 66.70,OTHER, 27.86, 120.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3850,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 43.51,OTHER, 20.72, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3851,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.00,,CLAIM ADJUSTMENT 3, 47.68,OTHER, 19.00, 86.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3852,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.86,,CLAIM ADJUSTMENT 3, 58.39,OTHER, 27.86, 103.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3853,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.86,,CLAIM ADJUSTMENT 3, 77.47,OTHER, 19.86, 145.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3854,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.74,,CLAIM ADJUSTMENT 3, 62.50,OTHER, 19.74, 116.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3855,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 46.75,OTHER, 17.35, 85.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3856,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.94,,CLAIM ADJUSTMENT 3, 41.14,OTHER, 16.94, 74.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3857,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 67.08,OTHER, 15.47, 127.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3858,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.84,,CLAIM ADJUSTMENT 3, 50.52,OTHER, 17.84, 92.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3859,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.21,,CLAIM ADJUSTMENT 3, 28.18,OTHER, 16.21, 48.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3860,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.79,,CLAIM ADJUSTMENT 3, 52.54,OTHER, 18.79, 96.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3861,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.79,,CLAIM ADJUSTMENT 3, 52.54,OTHER, 18.79, 96.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3862,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.07,,CLAIM ADJUSTMENT 3, 41.16,OTHER, 19.07, 73.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3863,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 46.11,OTHER, 20.72, 82.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3864,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 46.11,OTHER, 20.72, 82.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3865,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 46.11,OTHER, 20.72, 82.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3866,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 48.00,OTHER, 18.55, 88.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3867,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 48.00,OTHER, 18.55, 88.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3868,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 48.00,OTHER, 18.55, 88.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3869,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.07,,CLAIM ADJUSTMENT 3, 49.38,OTHER, 19.07, 89.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3870,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 80.11,OTHER, 18.55, 151.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3871,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 80.11,OTHER, 18.55, 151.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3872,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 361.76,OTHER, 18.55, 717.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3873,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.54,,CLAIM ADJUSTMENT 3, 161.64,OTHER, 20.54, 314.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3874,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 92.44,,CLAIM ADJUSTMENT 3, 158.63,OTHER, 92.44, 274.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3875,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 92.44,,CLAIM ADJUSTMENT 3, 158.63,OTHER, 92.44, 274.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3876,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.06,,CLAIM ADJUSTMENT 3, 78.01,OTHER, 14.06, 149.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3877,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.06,,CLAIM ADJUSTMENT 3, 78.01,OTHER, 14.06, 149.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3878,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.06,,CLAIM ADJUSTMENT 3, 78.01,OTHER, 14.06, 149.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3879,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 152.44,OTHER, 102.77, 234.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3880,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 251.30,,CLAIM ADJUSTMENT 3, 270.23,OTHER, 185.27, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3881,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 251.30,,CLAIM ADJUSTMENT 3, 270.23,OTHER, 185.27, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3882,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 251.30,,CLAIM ADJUSTMENT 3, 270.23,OTHER, 185.27, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3883,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3884,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3885,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3886,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3887,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3888,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 146.86,OTHER, 7.46, 291.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3889,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 54.74,OTHER, 4.31, 107.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3890,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 54.74,OTHER, 4.31, 107.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3891,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 54.74,OTHER, 4.31, 107.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3892,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 44.77,OTHER, 4.31, 89.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3893,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 44.77,OTHER, 4.31, 89.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3894,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 44.77,OTHER, 4.31, 89.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3895,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.52,,CLAIM ADJUSTMENT 3, 205.30,OTHER, 5.52, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3896,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.52,,CLAIM ADJUSTMENT 3, 205.30,OTHER, 5.52, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3897,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.52,,CLAIM ADJUSTMENT 3, 205.30,OTHER, 5.52, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3898,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.16,,CLAIM ADJUSTMENT 3, 70.78,OTHER, 11.16, 136.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3899,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.16,,CLAIM ADJUSTMENT 3, 70.78,OTHER, 11.16, 136.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3900,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3901,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3902,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3903,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3904,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3905,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3906,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 35.20,,CLAIM ADJUSTMENT 3, 76.50,OTHER, 35.20, 136.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3907,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 91.25,,CLAIM ADJUSTMENT 3, 149.18,OTHER, 91.25, 255.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3908,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.86,,CLAIM ADJUSTMENT 3, 81.41,OTHER, 14.86, 156.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3909,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.86,,CLAIM ADJUSTMENT 3, 81.41,OTHER, 14.86, 156.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3910,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.60,,CLAIM ADJUSTMENT 3, 30.76,OTHER, 13.60, 55.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3911,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.41,,CLAIM ADJUSTMENT 3, 72.64,OTHER, 12.41, 139.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3912,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.41,,CLAIM ADJUSTMENT 3, 72.64,OTHER, 12.41, 139.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3913,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.63,,CLAIM ADJUSTMENT 3, 78.26,OTHER, 13.63, 150.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3914,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.63,,CLAIM ADJUSTMENT 3, 78.26,OTHER, 13.63, 150.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3915,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 78.99,OTHER, 11.64, 152.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3916,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 46.77,OTHER, 11.64, 88.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3917,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 46.77,OTHER, 11.64, 88.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3918,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 46.77,OTHER, 11.64, 88.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3919,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.55,,CLAIM ADJUSTMENT 3, 40.96,OTHER, 9.55, 77.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3920,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.62,,CLAIM ADJUSTMENT 3, 44.68,OTHER, 11.62, 84.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3921,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.62,,CLAIM ADJUSTMENT 3, 44.68,OTHER, 11.62, 84.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3922,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.62,,CLAIM ADJUSTMENT 3, 44.68,OTHER, 11.62, 84.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3923,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.65,,CLAIM ADJUSTMENT 3, 82.26,OTHER, 11.65, 159.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3924,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.65,,CLAIM ADJUSTMENT 3, 82.26,OTHER, 11.65, 159.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3925,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.11,,CLAIM ADJUSTMENT 3, 74.74,OTHER, 12.11, 144.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3926,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 15.55,,CLAIM ADJUSTMENT 3, 91.00,OTHER, 15.55, 175.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3927,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.82,,CLAIM ADJUSTMENT 3, 68.31,OTHER, 12.82, 130.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3928,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 17.74,OTHER, 6.84, 32.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3929,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 10.78,,CLAIM ADJUSTMENT 3, 22.99,OTHER, 10.78, 40.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3930,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 29.95,OTHER, 6.84, 56.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3931,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.46,,CLAIM ADJUSTMENT 3, 42.41,OTHER, 12.46, 79.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3932,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3933,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3934,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3935,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3936,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3937,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 38.14,OTHER, 7.76, 72.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3938,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 38.14,OTHER, 7.76, 72.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3939,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.38,,CLAIM ADJUSTMENT 3, 28.29,OTHER, 8.38, 52.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3940,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 28.16,,CLAIM ADJUSTMENT 3, 68.72,OTHER, 28.16, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3941,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.26,,CLAIM ADJUSTMENT 3, 299.39,OTHER, 17.26, 592.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3942,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.88,,CLAIM ADJUSTMENT 3, 40.67,OTHER, 14.88, 74.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3943,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 43.08,OTHER, 16.61, 78.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3944,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 121.25,OTHER, 19.08, 234.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3945,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 28.87,,CLAIM ADJUSTMENT 3, 68.89,OTHER, 28.87, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3946,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 106.28,OTHER, 50.53, 189.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3947,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 106.28,OTHER, 50.53, 189.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3948,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 53.66,,CLAIM ADJUSTMENT 3, 107.02,OTHER, 53.66, 189.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3949,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 53.66,,CLAIM ADJUSTMENT 3, 107.02,OTHER, 53.66, 189.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3950,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 53.66,,CLAIM ADJUSTMENT 3, 107.02,OTHER, 53.66, 189.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3951,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 198.86,OTHER, 61.69, 369.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3952,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 198.86,OTHER, 61.69, 369.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3953,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3954,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 221.47,OTHER, 61.69, 415.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3955,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 76.43,OTHER, 50.53, 129.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3956,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 122.54,,CLAIM ADJUSTMENT 3, 265.03,OTHER, 122.54, 473.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3957,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 106.28,OTHER, 50.53, 189.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3958,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3959,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3960,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 600.16,,CLAIM ADJUSTMENT 3, 445.68,OTHER, 266.63, 607.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3961,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3962,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3963,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3964,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 193.99,OTHER, 50.53, 365.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3965,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 193.99,OTHER, 50.53, 365.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3966,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3967,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 173.66,OTHER, 50.53, 324.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3968,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 28.87,,CLAIM ADJUSTMENT 3, 68.89,OTHER, 28.87, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3969,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 204.22,OTHER, 50.53, 599.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3970,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 204.22,OTHER, 50.53, 599.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3971,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 146.52,OTHER, 61.69, 264.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3972,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 146.52,OTHER, 61.69, 264.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3973,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.83,,CLAIM ADJUSTMENT 3, 62.25,OTHER, 23.83, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3974,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.83,,CLAIM ADJUSTMENT 3, 62.25,OTHER, 23.83, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3975,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.86,,CLAIM ADJUSTMENT 3, 43.07,OTHER, 18.86, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3976,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.86,,CLAIM ADJUSTMENT 3, 43.07,OTHER, 18.86, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3977,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.81,,CLAIM ADJUSTMENT 3, 44.25,OTHER, 23.81, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3978,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.81,,CLAIM ADJUSTMENT 3, 17.88,OTHER, 10.75, 24.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3979,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.14,,CLAIM ADJUSTMENT 3, 100.14,OTHER, 23.14, 189.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3980,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 370.73,,CLAIM ADJUSTMENT 3, 800.72,OTHER, 370.73, 1429.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3981,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 370.73,,CLAIM ADJUSTMENT 3, 800.72,OTHER, 370.73, 1429.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3982,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 38.32,,CLAIM ADJUSTMENT 3, 59.91,OTHER, 38.32, 101.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3983,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 38.32,,CLAIM ADJUSTMENT 3, 59.91,OTHER, 38.32, 101.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3984,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 97.97,,CLAIM ADJUSTMENT 3, 294.34,OTHER, 97.97, 543.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3985,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3986,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3987,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.79,,CLAIM ADJUSTMENT 3, 16.75,OTHER, 6.79, 30.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3988,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.79,,CLAIM ADJUSTMENT 3, 16.75,OTHER, 6.79, 30.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3989,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.06,,CLAIM ADJUSTMENT 3, 56.81,OTHER, 8.06, 110.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3990,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 10.56,,CLAIM ADJUSTMENT 3, 39.98,OTHER, 10.56, 75.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3991,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 41.73,OTHER, 17.35, 75.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3992,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3993,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 63.90,OTHER, 37.34, 110.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3994,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 63.90,OTHER, 37.34, 110.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3995,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 23.30,OTHER, 12.69, 37.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3996,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 37.95,OTHER, 25.59, 58.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3997,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 23.42,OTHER, 12.79, 37.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 3998,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 3999,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4000,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 315.54,,CLAIM ADJUSTMENT 3, 149.84,OTHER, 65.79, 315.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4001,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 315.54,,CLAIM ADJUSTMENT 3, 149.84,OTHER, 65.79, 315.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4002,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4003,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 71.34,,CLAIM ADJUSTMENT 3, 41.40,OTHER, 21.50, 71.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4004,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 71.34,,CLAIM ADJUSTMENT 3, 41.40,OTHER, 21.50, 71.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4005,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 280.30,,CLAIM ADJUSTMENT 3, 356.50,OTHER, 255.16, 581.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4006,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 345.38,,CLAIM ADJUSTMENT 3, 687.64,OTHER, 345.38, 1214.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4007,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4008,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4009,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4010,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 77.65,,CLAIM ADJUSTMENT 3, 60.00,OTHER, 36.55, 83.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4011,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 48.79,,CLAIM ADJUSTMENT 3, 36.74,OTHER, 22.12, 50.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4012,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 48.79,,CLAIM ADJUSTMENT 3, 36.74,OTHER, 22.12, 50.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4013,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4014,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4015,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4016,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4017,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4018,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4019,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4020,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4021,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4022,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4023,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4024,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.83,,CLAIM ADJUSTMENT 3, 111.30,OTHER, 67.85, 154.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4025,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.83,,CLAIM ADJUSTMENT 3, 111.30,OTHER, 67.85, 154.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4026,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4027,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4028,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 89.44,,CLAIM ADJUSTMENT 3, 104.75,OTHER, 73.49, 167.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4029,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 89.44,,CLAIM ADJUSTMENT 3, 104.75,OTHER, 73.49, 167.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4030,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 33.16,,CLAIM ADJUSTMENT 3, 12.78,OTHER, 4.30, 33.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4031,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.09,,CLAIM ADJUSTMENT 3, 17.36,OTHER, 5.09, 32.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4032,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 184.48,OTHER, 130.68, 297.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4033,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 202.35,OTHER, 146.42, 333.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4034,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 113.95,,CLAIM ADJUSTMENT 3, 99.37,OTHER, 63.61, 144.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4035,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 59.56,,CLAIM ADJUSTMENT 3, 88.44,OTHER, 59.56, 149.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4036,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 131.72,OTHER, 84.22, 191.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4037,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 96.67,,CLAIM ADJUSTMENT 3, 117.05,OTHER, 82.81, 188.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4038,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 179.75,OTHER, 126.51, 288.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4039,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.72,,CLAIM ADJUSTMENT 3, 158.52,OTHER, 109.46, 249.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4040,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 186.21,OTHER, 132.20, 301.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4041,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.93,,CLAIM ADJUSTMENT 3, 83.96,OTHER, 50.93, 144.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4042,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 216.78,,CLAIM ADJUSTMENT 3, 167.44,OTHER, 102.00, 232.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4043,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 216.78,,CLAIM ADJUSTMENT 3, 172.28,OTHER, 106.26, 242.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4044,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 87.35,,CLAIM ADJUSTMENT 3, 49.86,OTHER, 25.59, 87.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4045,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 85.51,,CLAIM ADJUSTMENT 3, 141.43,OTHER, 85.51, 242.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4046,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 69.71,OTHER, 45.42, 103.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4047,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 177.65,OTHER, 120.47, 274.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4048,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 189.46,OTHER, 130.87, 298.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4049,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 279.93,OTHER, 171.54, 479.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4050,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 265.00,OTHER, 171.54, 449.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4051,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 113.59,,CLAIM ADJUSTMENT 3, 149.90,OTHER, 108.18, 246.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4052,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.09,,CLAIM ADJUSTMENT 3, 167.02,OTHER, 46.09, 313.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4053,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.09,,CLAIM ADJUSTMENT 3, 76.10,OTHER, 46.09, 130.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4054,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.09,,CLAIM ADJUSTMENT 3, 147.35,OTHER, 46.09, 273.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4055,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 227.22,OTHER, 124.32, 396.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4056,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 295.49,OTHER, 124.32, 533.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4057,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 114.40,OTHER, 74.67, 170.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4058,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 155.48,OTHER, 110.85, 252.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4059,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4060,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4061,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4062,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 114.13,,CLAIM ADJUSTMENT 3, 36.72,OTHER, 8.41, 114.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4063,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 114.13,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 114.13, 360.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4064,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 114.13,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 114.13, 360.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4065,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 346.21,,CLAIM ADJUSTMENT 3, 526.62,OTHER, 346.21, 891.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4066,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 346.21,,CLAIM ADJUSTMENT 3, 290.83,OTHER, 143.52, 346.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4067,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4068,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 49.24,,CLAIM ADJUSTMENT 3, 162.12,OTHER, 49.24, 301.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4069,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 80.99,,CLAIM ADJUSTMENT 3, 140.39,OTHER, 80.99, 243.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4070,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 80.99,,CLAIM ADJUSTMENT 3, 140.39,OTHER, 80.99, 243.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4071,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 51.13,,CLAIM ADJUSTMENT 3, 166.97,OTHER, 51.13, 310.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4072,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 51.13,,CLAIM ADJUSTMENT 3, 54.96,OTHER, 37.67, 85.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4073,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 51.13,,CLAIM ADJUSTMENT 3, 86.43,OTHER, 51.13, 149.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4074,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 656.16,,CLAIM ADJUSTMENT 3, 950.56,OTHER, 656.16, 1594.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4075,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 656.16,,CLAIM ADJUSTMENT 3, 375.80,OTHER, 121.44, 656.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4076,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 545.72,OTHER, 384.68, 911.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4077,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 545.72,OTHER, 384.68, 911.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4078,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 278.85,OTHER, 121.44, 384.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4079,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 278.85,OTHER, 121.44, 384.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4080,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 591.97,OTHER, 225.62, 1080.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4081,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4082,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 96.59,,CLAIM ADJUSTMENT 3, 250.40,OTHER, 96.59, 456.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4083,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 96.59,,CLAIM ADJUSTMENT 3, 250.40,OTHER, 96.59, 456.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4084,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 157.67,,CLAIM ADJUSTMENT 3, 197.77,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4085,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 563.65,OTHER, 225.62, 1023.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4086,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4087,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 113.30,OTHER, 70.09, 159.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4088,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 113.30,OTHER, 70.09, 159.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4089,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4090,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4091,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 297.88,OTHER, 215.00, 490.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4092,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4093,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 262.11,OTHER, 141.55, 458.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4094,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 262.11,OTHER, 141.55, 458.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4095,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4096,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4097,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 673.61,OTHER, 225.62, 1244.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4098,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 673.61,OTHER, 225.62, 1244.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4099,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 383.08,OTHER, 225.62, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4100,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 673.61,OTHER, 225.62, 1244.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4101,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4102,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4103,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4104,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4105,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4106,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4107,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4108,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4109,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4110,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4111,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4112,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4113,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 655.39,OTHER, 225.62, 1207.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4114,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4115,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 284.89,,CLAIM ADJUSTMENT 3, 1042.14,OTHER, 284.89, 2539.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4116,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 284.89,,CLAIM ADJUSTMENT 3, 1042.14,OTHER, 284.89, 2539.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4117,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 184.77,OTHER, 39.56, 427.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4118,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 184.77,OTHER, 39.56, 427.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4119,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.71,,CLAIM ADJUSTMENT 3, 547.41,OTHER, 138.71, 1032.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4120,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 152.82,,CLAIM ADJUSTMENT 3, 154.36,OTHER, 103.88, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4121,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 152.82,,CLAIM ADJUSTMENT 3, 154.36,OTHER, 103.88, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4122,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 199.86,OTHER, 125.79, 286.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4123,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 199.86,OTHER, 125.79, 286.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4124,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 407.38,OTHER, 140.42, 864.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4125,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 407.38,OTHER, 140.42, 864.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4126,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 407.38,OTHER, 140.42, 864.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4127,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 332.46,OTHER, 140.42, 600.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4128,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 239.03,OTHER, 160.29, 365.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4129,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 239.03,OTHER, 160.29, 365.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4130,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 174.98,OTHER, 103.88, 239.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4131,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 136.10,OTHER, 76.16, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4132,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 140.33,OTHER, 74.39, 234.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4133,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 87.35,,CLAIM ADJUSTMENT 3, 228.33,OTHER, 87.35, 416.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4134,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4135,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4136,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 94.34,,CLAIM ADJUSTMENT 3, 182.46,OTHER, 94.34, 321.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4137,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 94.34,,CLAIM ADJUSTMENT 3, 182.46,OTHER, 94.34, 321.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4138,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 125.89,OTHER, 61.67, 234.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4139,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 125.89,OTHER, 61.67, 234.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4140,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 235.80,,CLAIM ADJUSTMENT 3, 415.63,OTHER, 235.80, 721.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4141,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 1853.96,OTHER, 1121.15, 3185.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4142,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 1853.96,OTHER, 1121.15, 3185.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4143,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 2171.37,OTHER, 1121.15, 3822.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4144,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 2171.37,OTHER, 1121.15, 3822.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4145,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 2171.37,OTHER, 1121.15, 3822.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4146,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 85.61,,CLAIM ADJUSTMENT 3, 152.82,OTHER, 85.61, 265.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4147,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 89.47,,CLAIM ADJUSTMENT 3, 165.98,OTHER, 89.47, 290.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4148,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.12,,CLAIM ADJUSTMENT 3, 260.74,OTHER, 110.12, 470.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4149,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.12,,CLAIM ADJUSTMENT 3, 260.74,OTHER, 110.12, 470.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4150,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 96.89,OTHER, 37.34, 176.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4151,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 96.89,OTHER, 37.34, 176.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4152,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 184.46,,CLAIM ADJUSTMENT 3, 323.07,OTHER, 184.46, 560.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4153,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 184.46,,CLAIM ADJUSTMENT 3, 323.07,OTHER, 184.46, 560.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4154,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 184.46,,CLAIM ADJUSTMENT 3, 323.07,OTHER, 184.46, 560.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4155,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 89.33,OTHER, 37.34, 161.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4156,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 89.33,OTHER, 37.34, 161.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4157,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 108.89,OTHER, 54.48, 192.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4158,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 108.89,OTHER, 54.48, 192.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4159,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4160,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4161,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 84.04,OTHER, 37.34, 150.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4162,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 84.04,OTHER, 37.34, 150.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4163,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 37.95,OTHER, 25.59, 58.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4164,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 37.95,OTHER, 25.59, 58.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4165,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 159.88,OTHER, 54.48, 294.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4166,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 159.88,OTHER, 54.48, 294.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4167,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 96.44,OTHER, 54.48, 167.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4168,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 96.44,OTHER, 54.48, 167.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4169,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4170,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4171,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.01,,CLAIM ADJUSTMENT 3, 47.95,OTHER, 21.01, 86.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4172,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.01,,CLAIM ADJUSTMENT 3, 47.95,OTHER, 21.01, 86.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4173,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 34.39,,CLAIM ADJUSTMENT 3, 55.33,OTHER, 34.39, 94.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4174,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 34.39,,CLAIM ADJUSTMENT 3, 55.33,OTHER, 34.39, 94.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4175,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.74,,CLAIM ADJUSTMENT 3, 58.74,OTHER, 29.74, 103.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4176,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.74,,CLAIM ADJUSTMENT 3, 58.74,OTHER, 29.74, 103.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4177,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.74,,CLAIM ADJUSTMENT 3, 58.74,OTHER, 29.74, 103.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4178,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 28.82,,CLAIM ADJUSTMENT 3, 142.33,OTHER, 28.82, 411.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4179,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 28.82,,CLAIM ADJUSTMENT 3, 142.33,OTHER, 28.82, 411.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4180,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 28.82,,CLAIM ADJUSTMENT 3, 72.71,OTHER, 28.82, 132.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4181,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 74.33,OTHER, 52.80, 120.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4182,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 74.33,OTHER, 52.80, 120.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4183,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 74.35,OTHER, 52.84, 120.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4184,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 69.01,,CLAIM ADJUSTMENT 3, 80.43,OTHER, 56.36, 128.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4185,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 69.01,,CLAIM ADJUSTMENT 3, 80.43,OTHER, 56.36, 128.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4186,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 69.01,,CLAIM ADJUSTMENT 3, 80.43,OTHER, 56.36, 128.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4187,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 60.80,OTHER, 40.91, 93.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4188,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 60.80,OTHER, 40.91, 93.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4189,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 61.55,,CLAIM ADJUSTMENT 3, 47.68,OTHER, 29.08, 66.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4190,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.96,,CLAIM ADJUSTMENT 3, 98.59,OTHER, 46.96, 175.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4191,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.96,,CLAIM ADJUSTMENT 3, 98.59,OTHER, 46.96, 175.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4192,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.96,,CLAIM ADJUSTMENT 3, 98.59,OTHER, 46.96, 175.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4193,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 44.87,,CLAIM ADJUSTMENT 3, 115.67,OTHER, 44.87, 210.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4194,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 44.87,,CLAIM ADJUSTMENT 3, 115.67,OTHER, 44.87, 210.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4195,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 44.87,,CLAIM ADJUSTMENT 3, 115.67,OTHER, 44.87, 210.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4196,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 55.58,,CLAIM ADJUSTMENT 3, 73.14,OTHER, 52.75, 120.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4197,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 55.58,,CLAIM ADJUSTMENT 3, 73.14,OTHER, 52.75, 120.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4198,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 55.58,,CLAIM ADJUSTMENT 3, 73.14,OTHER, 52.75, 120.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4199,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.13,,CLAIM ADJUSTMENT 3, 30.33,OTHER, 18.92, 43.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4200,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.21,,CLAIM ADJUSTMENT 3, 178.52,OTHER, 113.97, 259.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4201,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.21,,CLAIM ADJUSTMENT 3, 202.67,OTHER, 135.24, 308.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4202,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.21,,CLAIM ADJUSTMENT 3, 194.50,OTHER, 128.04, 291.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4203,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 142.50,,CLAIM ADJUSTMENT 3, 106.37,OTHER, 63.79, 145.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4204,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 208.14,,CLAIM ADJUSTMENT 3, 173.75,OTHER, 109.36, 249.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4205,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 208.14,,CLAIM ADJUSTMENT 3, 180.83,OTHER, 115.60, 263.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4206,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 208.14,,CLAIM ADJUSTMENT 3, 204.49,OTHER, 136.43, 310.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4207,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.15,,CLAIM ADJUSTMENT 3, 108.91,OTHER, 65.89, 150.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4208,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 41.16,,CLAIM ADJUSTMENT 3, 68.75,OTHER, 41.16, 118.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4209,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 41.16,,CLAIM ADJUSTMENT 3, 68.75,OTHER, 41.16, 118.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4210,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 41.16,,CLAIM ADJUSTMENT 3, 68.75,OTHER, 41.16, 118.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4211,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 44.69,OTHER, 31.56, 71.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4212,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 66.74,,CLAIM ADJUSTMENT 3, 78.22,OTHER, 54.89, 125.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4213,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 66.74,,CLAIM ADJUSTMENT 3, 78.22,OTHER, 54.89, 125.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4214,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 66.74,,CLAIM ADJUSTMENT 3, 59.17,OTHER, 38.11, 86.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4215,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 39.73,,CLAIM ADJUSTMENT 3, 66.10,OTHER, 39.73, 113.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4216,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 39.73,,CLAIM ADJUSTMENT 3, 66.10,OTHER, 39.73, 113.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4217,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 39.73,,CLAIM ADJUSTMENT 3, 66.10,OTHER, 39.73, 113.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4218,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 68.90,OTHER, 12.81, 151.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4219,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 96.26,,CLAIM ADJUSTMENT 3, 93.12,OTHER, 61.82, 140.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4220,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 84.59,,CLAIM ADJUSTMENT 3, 114.40,OTHER, 52.03, 259.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4221,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 84.59,,CLAIM ADJUSTMENT 3, 114.40,OTHER, 52.03, 259.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4222,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.23,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 53.32, 121.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4223,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.23,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 53.32, 121.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4224,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.23,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 53.32, 121.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4225,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4226,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4227,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4228,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4229,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4230,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4231,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4232,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4233,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4234,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4235,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 114.64,,CLAIM ADJUSTMENT 3, 145.27,OTHER, 103.88, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4236,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4237,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4238,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4239,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4240,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4241,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4242,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4243,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4244,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4245,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4246,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4247,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4248,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4249,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4250,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4251,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4252,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4253,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4254,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4255,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 103.66,,CLAIM ADJUSTMENT 3, 111.61,OTHER, 64.03, 142.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4256,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 164.56,,CLAIM ADJUSTMENT 3, 149.82,OTHER, 78.16, 173.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4257,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 247.58,,CLAIM ADJUSTMENT 3, 220.11,OTHER, 113.05, 250.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4258,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 149.74,OTHER, 77.35, 263.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4259,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 149.74,OTHER, 77.35, 263.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4260,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 156.74,OTHER, 77.35, 245.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4261,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 156.74,OTHER, 77.35, 245.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4262,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 233.57,OTHER, 127.82, 407.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4263,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 233.57,OTHER, 127.82, 407.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4264,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 197.91,OTHER, 127.82, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4265,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 197.91,OTHER, 127.82, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4266,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 369.55,OTHER, 203.96, 644.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4267,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 369.55,OTHER, 203.96, 644.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4268,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 247.74,OTHER, 150.14, 333.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4269,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 247.74,OTHER, 150.14, 333.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4270,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 580.80,OTHER, 324.71, 1010.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4271,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 580.80,OTHER, 324.71, 1010.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4272,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 332.53,OTHER, 185.91, 412.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4273,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 332.53,OTHER, 185.91, 412.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4274,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 479.76,,CLAIM ADJUSTMENT 3, 954.02,OTHER, 479.76, 1685.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4275,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 479.76,,CLAIM ADJUSTMENT 3, 954.02,OTHER, 479.76, 1685.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4276,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 479.76,,CLAIM ADJUSTMENT 3, 429.06,OTHER, 221.24, 490.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4277,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 720.78,,CLAIM ADJUSTMENT 3, 1514.86,OTHER, 720.78, 2695.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4278,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4279,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4280,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4281,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4282,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 167.97,OTHER, 113.31, 258.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4283,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 173.37,OTHER, 118.06, 269.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4284,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 179.18,OTHER, 123.17, 280.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4285,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 197.44,OTHER, 139.26, 317.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4286,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 192.88,OTHER, 135.24, 308.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4287,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4288,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4289,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 155.10,OTHER, 101.97, 232.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4290,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 162.99,OTHER, 108.92, 248.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4291,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 174.20,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4292,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 174.20,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4293,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 174.20,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4294,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 177.10,OTHER, 121.35, 276.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4295,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4296,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4297,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4298,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4299,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4300,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4301,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.74,,CLAIM ADJUSTMENT 3, 33.14,OTHER, 22.74, 51.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4302,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.74,,CLAIM ADJUSTMENT 3, 39.28,OTHER, 28.14, 64.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4303,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4304,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4305,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4306,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4307,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 101.33,,CLAIM ADJUSTMENT 3, 148.65,OTHER, 101.33, 249.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4308,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.36,,CLAIM ADJUSTMENT 3, 166.04,OTHER, 118.25, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4309,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4310,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4311,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 680.93,,CLAIM ADJUSTMENT 3, 350.13,OTHER, 165.55, 680.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4312,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 680.93,,CLAIM ADJUSTMENT 3, 350.13,OTHER, 165.55, 680.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4313,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1078.14,,CLAIM ADJUSTMENT 3, 553.11,OTHER, 261.01, 1078.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4314,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1078.14,,CLAIM ADJUSTMENT 3, 553.11,OTHER, 261.01, 1078.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4315,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 567.43,,CLAIM ADJUSTMENT 3, 308.45,OTHER, 152.65, 567.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4316,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 567.43,,CLAIM ADJUSTMENT 3, 308.45,OTHER, 152.65, 567.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4317,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 907.91,,CLAIM ADJUSTMENT 3, 466.19,OTHER, 220.16, 907.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4318,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 907.91,,CLAIM ADJUSTMENT 3, 466.19,OTHER, 220.16, 907.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4319,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4320,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4321,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4322,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4323,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4324,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4325,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4326,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1648.47,OTHER, 779.04, 2936.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4327,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1648.47,OTHER, 779.04, 2936.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4328,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1777.88,OTHER, 779.04, 3195.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4329,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1777.88,OTHER, 779.04, 3195.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4330,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1244.21,OTHER, 508.57, 2254.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4331,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1244.21,OTHER, 508.57, 2254.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4332,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1244.21,OTHER, 508.57, 2254.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4333,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1097.72,OTHER, 508.57, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4334,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1097.72,OTHER, 508.57, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4335,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1162.11,OTHER, 779.04, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4336,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1162.11,OTHER, 779.04, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4337,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1.66,,CLAIM ADJUSTMENT 3, 9.74,OTHER, 1.66, 18.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4338,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 63.90,OTHER, 37.34, 110.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4339,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 11.82,OTHER, 2.58, 37.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4340,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4341,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4342,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 33.71,,CLAIM ADJUSTMENT 3, 88.75,OTHER, 33.71, 162.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4343,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 33.71,,CLAIM ADJUSTMENT 3, 58.81,OTHER, 33.71, 101.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4344,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4345,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 231.89,OTHER, 165.06, 386.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4346,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 231.89,OTHER, 165.06, 386.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4347,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 35.44,OTHER, 18.28, 61.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4348,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 44.57,OTHER, 26.32, 61.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4349,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4350,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4351,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4352,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4353,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4354,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4355,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4356,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4357,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4358,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4359,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4360,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4361,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4362,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4363,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4364,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4365,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4366,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4367,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4368,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4369,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4370,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4371,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4372,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4373,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1597.44,,CLAIM ADJUSTMENT 3, 575.18,OTHER, 171.57, 1597.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4374,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2082.47,,CLAIM ADJUSTMENT 3, 690.66,OTHER, 171.57, 2082.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4375,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1937.50,,CLAIM ADJUSTMENT 3, 656.15,OTHER, 171.57, 1937.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4376,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1734.01,,CLAIM ADJUSTMENT 3, 607.70,OTHER, 171.57, 1734.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4377,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2065.06,,CLAIM ADJUSTMENT 3, 735.35,OTHER, 214.57, 2065.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4378,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.42,,CLAIM ADJUSTMENT 3, 421.89,OTHER, 18.42, 837.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4379,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4380,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4381,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4382,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4383,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4384,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4385,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4386,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4387,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4388,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4389,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4390,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4391,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4392,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4393,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4394,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4395,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4396,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4397,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4398,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4399,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4400,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4401,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4402,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4403,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4404,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4405,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4406,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4407,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4408,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4409,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4410,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4411,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4412,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4413,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4414,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4415,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4416,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 42.53,,CLAIM ADJUSTMENT 3, 62.01,OTHER, 42.53, 104.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4417,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4418,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4419,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4420,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4421,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4422,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4423,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4424,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4425,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4426,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4427,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4428,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4429,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4430,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4431,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4432,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4433,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4434,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4435,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4436,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4437,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4438,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4439,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4440,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4441,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4442,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4443,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4444,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4445,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4446,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4447,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4448,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4449,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4450,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4451,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4452,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4453,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4454,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4455,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4456,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4457,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4458,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4459,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4460,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4461,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4462,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4463,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4464,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4465,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4466,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4467,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4468,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4469,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4470,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4471,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4472,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4473,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4474,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4475,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4476,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4477,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4478,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4479,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4480,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4481,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4482,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4483,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4484,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4485,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4486,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4487,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4488,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4489,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4490,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4491,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4492,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4493,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4494,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4495,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4496,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4497,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4498,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4499,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4500,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4501,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4502,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4503,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4504,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4505,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4506,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4507,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4508,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4509,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4510,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4511,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4512,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4513,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4514,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4515,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4516,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4517,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4518,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4519,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4520,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4521,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4522,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4523,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4524,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4525,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4526,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4527,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4528,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4529,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4530,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4531,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4532,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4533,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4534,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4535,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4536,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4537,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4538,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4539,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4540,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4541,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4542,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4543,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4544,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4545,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4546,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4547,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4548,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 4549,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,BCBSNM_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 4550,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1069.50,,OUTPCT LIMIT, 920.20,OTHER, 507.84, 1127.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4551,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 790.50,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4552,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1278.75,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4553,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4554,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4555,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4556,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4557,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4558,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4559,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4560,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4561,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4562,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4563,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4564,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4565,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4566,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4567,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4568,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 452.72,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4569,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 452.72,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4570,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 256.91,,OUTPCT LIMIT, 168.89,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4571,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 217.62,,OUTPCT LIMIT, 171.36,OTHER, 103.33, 229.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4572,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 456.84,,OUTPCT LIMIT, 273.87,OTHER, 142.76, 481.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4573,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 408.27,,OUTPCT LIMIT, 276.81,OTHER, 142.76, 430.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4574,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 336.75,,OUTPCT LIMIT, 242.16,OTHER, 155.70, 354.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4575,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 428.73,,OUTPCT LIMIT, 850.02,OTHER, 203.58, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4576,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 408.27,,OUTPCT LIMIT, 667.92,OTHER, 193.86, 1237.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4577,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 143.22,,OUTPCT LIMIT, 177.23,OTHER, 68.01, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4578,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 65.10,,OUTPCT LIMIT, 131.69,OTHER, 30.91, 267.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4579,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 118.11,,OUTPCT LIMIT, 116.49,OTHER, 56.08, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4580,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 567.30,,OUTPCT LIMIT, 405.48,OTHER, 256.74, 597.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4581,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 341.31,,OUTPCT LIMIT, 293.67,OTHER, 162.07, 359.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4582,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 225.99,,OUTPCT LIMIT, 216.69,OTHER, 107.31, 256.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4583,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 71.61,,OUTPCT LIMIT, 61.61,OTHER, 34.00, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4584,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 127.41,,OUTPCT LIMIT, 233.68,OTHER, 60.50, 456.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4585,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 194.37,,OUTPCT LIMIT, 158.67,OTHER, 92.29, 204.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4586,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 147.87,,OUTPCT LIMIT, 112.58,OTHER, 70.21, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4587,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 171.12,,OUTPCT LIMIT, 125.44,OTHER, 81.25, 180.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4588,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 108.81,,OUTPCT LIMIT, 114.17,OTHER, 51.67, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4589,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 128.34,,OUTPCT LIMIT, 122.15,OTHER, 60.94, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4590,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 195.30,,OUTPCT LIMIT, 138.81,OTHER, 86.20, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4591,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 156.24,,OUTPCT LIMIT, 117.21,OTHER, 74.19, 164.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4592,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 190.65,,OUTPCT LIMIT, 258.26,OTHER, 90.53, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4593,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 243.66,,OUTPCT LIMIT, 287.58,OTHER, 115.70, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4594,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 328.29,,OUTPCT LIMIT, 334.39,OTHER, 155.88, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4595,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2218.98,,OUTPCT LIMIT, 1514.68,OTHER, 804.50, 2338.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4596,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1253.64,,OUTPCT LIMIT, 1306.30,OTHER, 595.28, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4597,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 565.44,,OUTPCT LIMIT, 925.64,OTHER, 268.49, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4598,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 185.07,,OUTPCT LIMIT, 389.69,OTHER, 87.88, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4599,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 252.96,,OUTPCT LIMIT, 427.24,OTHER, 120.12, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4600,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 307.83,,OUTPCT LIMIT, 457.59,OTHER, 146.17, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4601,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 216.69,,OUTPCT LIMIT, 732.74,OTHER, 102.89, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4602,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 631.47,,OUTPCT LIMIT, 1168.49,OTHER, 299.85, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4603,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 266.91,,OUTPCT LIMIT, 300.44,OTHER, 126.74, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4604,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 375.72,,OUTPCT LIMIT, 495.14,OTHER, 178.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4605,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 447.33,,OUTPCT LIMIT, 534.75,OTHER, 212.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4606,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 516.15,,OUTPCT LIMIT, 572.81,OTHER, 245.09, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4607,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 460.35,,OUTPCT LIMIT, 541.95,OTHER, 218.59, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4608,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 527.31,,OUTPCT LIMIT, 578.99,OTHER, 250.39, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4609,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1614.48,,OUTPCT LIMIT, 1505.88,OTHER, 766.62, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4610,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 650.07,,OUTPCT LIMIT, 646.89,OTHER, 308.68, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4611,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 765.39,,OUTPCT LIMIT, 1242.56,OTHER, 363.44, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4612,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 408.27,,OUTPCT LIMIT, 513.14,OTHER, 193.86, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4613,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 422.22,,OUTPCT LIMIT, 520.86,OTHER, 200.49, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4614,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 736.56,,OUTPCT LIMIT, 694.73,OTHER, 349.75, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4615,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 605.43,,OUTPCT LIMIT, 947.76,OTHER, 287.48, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4616,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1037.88,,OUTPCT LIMIT, 1393.28,OTHER, 492.83, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4617,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 52.08,,OUTPCT LIMIT, 56.01,OTHER, 24.73, 76.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4618,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 314.25,,OUTPCT LIMIT, 185.53,OTHER, 86.20, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4619,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 120.23,,OUTPCT LIMIT, 97.29,OTHER, 57.09, 126.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4620,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 119.97,,OUTPCT LIMIT, 97.14,OTHER, 56.97, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4621,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 47.43,,OUTPCT LIMIT, 57.02,OTHER, 22.52, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4622,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 398.04,,OUTPCT LIMIT, 372.97,OTHER, 189.00, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4623,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1134.60,,OUTPCT LIMIT, 1446.78,OTHER, 538.75, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4624,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 546.84,,OUTPCT LIMIT, 1121.68,OTHER, 259.66, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4625,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 356.88,,OUTPCT LIMIT, 278.63,OTHER, 165.01, 383.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4626,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 640.62,,OUTPCT LIMIT, 427.61,OTHER, 296.20, 675.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4627,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 387.67,,OUTPCT LIMIT, 237.66,OTHER, 143.26, 408.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4628,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 418.13,,OUTPCT LIMIT, 253.66,OTHER, 143.26, 440.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4629,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 453.38,,OUTPCT LIMIT, 272.17,OTHER, 143.26, 477.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4630,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 413.82,,OUTPCT LIMIT, 251.39,OTHER, 143.26, 436.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4631,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 380.37,,OUTPCT LIMIT, 261.55,OTHER, 143.26, 400.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4632,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 438.89,,OUTPCT LIMIT, 264.56,OTHER, 143.26, 462.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4633,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 443.33,,OUTPCT LIMIT, 306.35,OTHER, 204.98, 467.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4634,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 791.43,,OUTPCT LIMIT, 548.12,OTHER, 309.01, 833.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4635,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 457.56,,OUTPCT LIMIT, 300.52,OTHER, 132.82, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4636,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 497.95,,OUTPCT LIMIT, 293.08,OTHER, 132.82, 524.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4637,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1809.65,,OUTPCT LIMIT, 1023.77,OTHER, 309.01, 1906.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4638,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 701.22,,OUTPCT LIMIT, 498.22,OTHER, 309.01, 738.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4639,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3046.92,,OUTPCT LIMIT, 1703.49,OTHER, 435.32, 3210.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4640,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 806.31,,OUTPCT LIMIT, 601.46,OTHER, 382.87, 849.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4641,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2513.79,,OUTPCT LIMIT, 2228.68,OTHER, 1193.64, 2648.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4642,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2730.48,,OUTPCT LIMIT, 2329.49,OTHER, 1296.54, 2877.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4643,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 119.04,,OUTPCT LIMIT, 163.86,OTHER, 56.52, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4644,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 314.25,,OUTPCT LIMIT, 200.99,OTHER, 145.30, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4645,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 112.53,,OUTPCT LIMIT, 93.03,OTHER, 53.43, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4646,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 12.09,,OUTPCT LIMIT, 22.22,OTHER, 5.74, 43.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4647,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 308.76,,OUTPCT LIMIT, 224.77,OTHER, 146.61, 325.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4648,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 163.68,,OUTPCT LIMIT, 251.63,OTHER, 77.72, 451.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4649,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 508.71,,OUTPCT LIMIT, 1148.36,OTHER, 241.56, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4650,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1206.21,,OUTPCT LIMIT, 1534.16,OTHER, 572.76, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4651,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 257.61,,OUTPCT LIMIT, 232.01,OTHER, 122.32, 271.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4652,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 123.32,,OUTPCT LIMIT, 124.43,OTHER, 57.02, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4653,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 115.32,,OUTPCT LIMIT, 120.23,OTHER, 53.32, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4654,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 134.39,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4655,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 134.39,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4656,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 7929.18,,OUTPCT LIMIT, 5204.99,OTHER, 2293.79, 8355.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4657,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 578.46,,OUTPCT LIMIT, 932.84,OTHER, 274.68, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4658,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 734.89,,OUTPCT LIMIT, 424.57,OTHER, 162.56, 774.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4659,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 564.09,,OUTPCT LIMIT, 334.89,OTHER, 162.56, 594.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4660,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1073.99,,OUTPCT LIMIT, 675.88,OTHER, 470.23, 1131.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4661,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 878.11,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4662,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 878.11,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4663,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 321.83,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4664,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 321.83,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4665,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 289.67,,OUTPCT LIMIT, 176.70,OTHER, 103.34, 305.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4666,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1050.85,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4667,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1050.85,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4668,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1828.32,,OUTPCT LIMIT, 1089.64,OTHER, 544.52, 1926.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4669,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 32.55,,OUTPCT LIMIT, 22.43,OTHER, 15.05, 34.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4670,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 28.88,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4671,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 28.88,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4672,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 28.88,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4673,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 28.88,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4674,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 28.88,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4675,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 28.88,,OUTPCT LIMIT, 20.38,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4676,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 23.25,,OUTPCT LIMIT, 16.02,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4677,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 952.42,,OUTPCT LIMIT, 579.04,OTHER, 331.58, 1003.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4678,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2051.58,,OUTPCT LIMIT, 1525.88,OTHER, 974.17, 2161.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4679,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 5803.20,,OUTPCT LIMIT, 4097.24,OTHER, 2484.68, 6115.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4680,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 6172.41,,OUTPCT LIMIT, 4480.28,OTHER, 2930.90, 6504.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4681,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 763.53,,OUTPCT LIMIT, 813.44,OTHER, 362.55, 1095.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4682,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 6688.56,,OUTPCT LIMIT, 4090.68,OTHER, 1095.12, 7048.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4683,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 224.68,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4684,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 224.68,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4685,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 587.76,,OUTPCT LIMIT, 1187.28,OTHER, 279.09, 2414.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4686,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 363.63,,OUTPCT LIMIT, 803.17,OTHER, 172.67, 1685.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4687,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2045.07,,OUTPCT LIMIT, 1733.21,OTHER, 971.08, 2155.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4688,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2624.46,,OUTPCT LIMIT, 1757.99,OTHER, 857.80, 2765.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4689,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 309.69,,OUTPCT LIMIT, 477.65,OTHER, 147.05, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4690,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 345.96,,OUTPCT LIMIT, 497.71,OTHER, 164.28, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4691,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2184.57,,OUTPCT LIMIT, 1514.68,OTHER, 857.80, 2302.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4692,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3086.67,,OUTPCT LIMIT, 2013.65,OTHER, 857.80, 3252.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4693,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 439.89,,OUTPCT LIMIT, 549.67,OTHER, 208.88, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4694,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 491.97,,OUTPCT LIMIT, 578.48,OTHER, 233.61, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4695,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2563.08,,OUTPCT LIMIT, 2205.29,OTHER, 1217.05, 2700.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4696,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3138.75,,OUTPCT LIMIT, 2700.60,OTHER, 1490.40, 3307.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4697,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1084.59,,OUTPCT LIMIT, 718.33,OTHER, 501.48, 1142.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4698,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2832.78,,OUTPCT LIMIT, 2437.34,OTHER, 1345.11, 2985.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4699,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1498.23,,OUTPCT LIMIT, 1780.93,OTHER, 711.42, 2666.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4700,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1394.07,,OUTPCT LIMIT, 2411.76,OTHER, 661.96, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4701,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 146.94,,OUTPCT LIMIT, 283.55,OTHER, 69.77, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4702,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 174.84,,OUTPCT LIMIT, 298.98,OTHER, 83.02, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4703,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 287.37,,OUTPCT LIMIT, 482.77,OTHER, 136.45, 906.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4704,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 515.22,,OUTPCT LIMIT, 603.90,OTHER, 244.65, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4705,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 603.57,,OUTPCT LIMIT, 652.77,OTHER, 286.60, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4706,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 786.78,,OUTPCT LIMIT, 754.11,OTHER, 373.59, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4707,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 717.96,,OUTPCT LIMIT, 716.04,OTHER, 340.92, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4708,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 691.92,,OUTPCT LIMIT, 701.64,OTHER, 328.55, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4709,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3536.79,,OUTPCT LIMIT, 2366.55,OTHER, 1148.80, 3726.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4710,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 233.43,,OUTPCT LIMIT, 623.49,OTHER, 110.84, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4711,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 335.73,,OUTPCT LIMIT, 256.43,OTHER, 159.42, 353.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4712,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 258.54,,OUTPCT LIMIT, 637.38,OTHER, 122.76, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4713,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 258.54,,OUTPCT LIMIT, 982.61,OTHER, 122.76, 2350.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4714,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1378.26,,OUTPCT LIMIT, 1507.20,OTHER, 654.45, 2085.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4715,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3480.99,,OUTPCT LIMIT, 3143.54,OTHER, 1652.91, 3668.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4716,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1528.92,,OUTPCT LIMIT, 2486.35,OTHER, 725.99, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4717,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1661.91,,OUTPCT LIMIT, 2559.90,OTHER, 789.14, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4718,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1656.33,,OUTPCT LIMIT, 1425.12,OTHER, 786.49, 1745.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4719,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2665.38,,OUTPCT LIMIT, 1667.02,OTHER, 539.71, 2808.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4720,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1205.28,,OUTPCT LIMIT, 1786.42,OTHER, 572.31, 3135.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4721,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3294.06,,OUTPCT LIMIT, 3662.54,OTHER, 1564.15, 5153.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4722,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 340.38,,OUTPCT LIMIT, 889.66,OTHER, 161.63, 1963.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4723,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 374.74,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4724,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 374.74,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4725,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2533.32,,OUTPCT LIMIT, 2146.09,OTHER, 1202.92, 2669.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4726,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 199.77,OTHER, 96.75, 377.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4727,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 266.50,OTHER, 96.75, 657.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4728,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3197.34,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4729,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3197.34,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4730,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1044.25,,OUTPCT LIMIT, 719.65,OTHER, 482.83, 1100.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4731,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1867.95,,OUTPCT LIMIT, 1287.31,OTHER, 863.68, 1968.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4732,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 422.13,,OUTPCT LIMIT, 290.91,OTHER, 195.18, 444.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4733,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1575.42,,OUTPCT LIMIT, 2579.17,OTHER, 748.07, 4781.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4734,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 242.84,,OUTPCT LIMIT, 162.43,OTHER, 112.28, 255.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4735,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 210.25,,OUTPCT LIMIT, 145.32,OTHER, 97.21, 221.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4736,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 134.29,,OUTPCT LIMIT, 116.13,OTHER, 62.09, 191.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4737,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 110.67,,OUTPCT LIMIT, 76.24,OTHER, 51.17, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4738,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 198.15,,OUTPCT LIMIT, 124.60,OTHER, 86.34, 208.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4739,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4740,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.98,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4741,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4742,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 127.41,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4743,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4744,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 244.83,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4745,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4746,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.98,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4747,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4748,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 264.84,,OUTPCT LIMIT, 171.96,OTHER, 122.45, 279.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4749,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4750,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 204.14,,OUTPCT LIMIT, 127.74,OTHER, 86.34, 215.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4751,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4752,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 298.40,,OUTPCT LIMIT, 189.58,OTHER, 137.97, 314.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4753,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4754,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 183.52,,OUTPCT LIMIT, 116.92,OTHER, 84.85, 193.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4755,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4756,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 507.81,,OUTPCT LIMIT, 299.54,OTHER, 138.19, 535.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4757,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4758,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 358.31,,OUTPCT LIMIT, 221.04,OTHER, 138.19, 377.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4759,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4760,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 275.28,,OUTPCT LIMIT, 177.44,OTHER, 127.28, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4761,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4762,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 96.47,,OUTPCT LIMIT, 71.21,OTHER, 44.60, 101.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4763,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4764,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 329.48,,OUTPCT LIMIT, 193.56,OTHER, 86.34, 347.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4765,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4766,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 386.51,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4767,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2723.17,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4768,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2024.13,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4769,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4770,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4771,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2081.90,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4772,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2081.90,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4773,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4774,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4775,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2723.17,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4776,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2723.17,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4777,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4778,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4779,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1690.49,,OUTPCT LIMIT, 955.20,OTHER, 283.82, 1781.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4780,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4781,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1120.71,,OUTPCT LIMIT, 691.35,OTHER, 432.18, 1180.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4782,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4783,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1469.40,,OUTPCT LIMIT, 887.08,OTHER, 485.27, 1548.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4784,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4785,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1587.51,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4786,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1587.86,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4787,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4788,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4789,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1815.05,,OUTPCT LIMIT, 1055.93,OTHER, 432.18, 1912.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4790,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2285.00,,OUTPCT LIMIT, 1302.68,OTHER, 432.18, 2407.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4791,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4792,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4793,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 757.02,,OUTPCT LIMIT, 513.03,OTHER, 350.02, 797.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4794,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4795,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2329.24,,OUTPCT LIMIT, 1290.59,OTHER, 283.82, 2454.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4796,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4797,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2422.37,,OUTPCT LIMIT, 1374.81,OTHER, 432.18, 2552.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4798,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4799,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2190.99,,OUTPCT LIMIT, 1265.96,OTHER, 485.27, 2308.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4800,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4801,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1824.89,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4802,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1824.89,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4803,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1824.89,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4804,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4805,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4806,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4807,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2195.64,,OUTPCT LIMIT, 1270.81,OTHER, 495.38, 2313.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4808,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4809,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2849.21,,OUTPCT LIMIT, 1681.52,OTHER, 779.04, 3002.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4810,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4811,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2102.16,,OUTPCT LIMIT, 1224.87,OTHER, 508.57, 2215.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4812,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4813,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2242.23,,OUTPCT LIMIT, 1324.21,OTHER, 616.91, 2362.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4814,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4815,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2566.34,,OUTPCT LIMIT, 1532.99,OTHER, 779.04, 2704.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4816,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4817,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2118.77,,OUTPCT LIMIT, 1233.59,OTHER, 508.57, 2232.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4818,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4819,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2112.96,,OUTPCT LIMIT, 1256.33,OTHER, 616.91, 2226.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4820,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4821,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2429.39,,OUTPCT LIMIT, 1461.09,OTHER, 779.04, 2560.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4822,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4823,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2461.72,,OUTPCT LIMIT, 1413.66,OTHER, 508.57, 2594.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4824,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4825,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3800.84,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4826,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3800.84,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4827,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4828,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4829,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.98,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4830,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.98,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4831,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.98,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4832,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.98,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4833,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4834,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4835,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4836,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4837,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.98,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4838,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4839,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.98,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4840,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.98,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4841,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4842,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4843,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 421.84,,OUTPCT LIMIT, 242.05,OTHER, 86.34, 444.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4844,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 424.63,,OUTPCT LIMIT, 243.52,OTHER, 86.34, 447.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4845,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4846,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4847,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 345.16,,OUTPCT LIMIT, 214.14,OTHER, 138.19, 363.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4848,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 394.47,,OUTPCT LIMIT, 240.03,OTHER, 138.19, 415.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4849,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4850,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4851,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 411.31,,OUTPCT LIMIT, 248.87,OTHER, 138.19, 433.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4852,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4853,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 275.28,,OUTPCT LIMIT, 165.10,OTHER, 86.34, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4854,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4855,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.98,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4856,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4857,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2178.43,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4858,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2178.43,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4859,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2178.43,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4860,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4861,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4862,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2178.43,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4863,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2597.97,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4864,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4865,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3240.92,,OUTPCT LIMIT, 1817.25,OTHER, 485.27, 3415.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4866,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4867,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2178.43,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4868,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2178.43,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4869,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2178.43,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4870,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4871,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4872,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4873,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4631.43,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4874,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3120.78,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4875,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3120.78,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4876,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3120.78,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4877,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3120.78,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4878,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4879,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4880,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4881,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4882,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1177.38,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4883,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2627.25,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4884,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4885,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4886,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 282.72,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4887,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 282.72,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4888,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4889,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4890,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 409.00,,OUTPCT LIMIT, 247.65,OTHER, 138.19, 430.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4891,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4892,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 605.06,,OUTPCT LIMIT, 350.60,OTHER, 138.19, 637.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4893,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4894,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 666.06,,OUTPCT LIMIT, 382.63,OTHER, 138.19, 701.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4895,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4896,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 496.30,,OUTPCT LIMIT, 293.50,OTHER, 138.19, 522.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4897,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4898,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 443.67,,OUTPCT LIMIT, 265.86,OTHER, 138.19, 467.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4899,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4900,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 244.83,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4901,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4902,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 232.50,,OUTPCT LIMIT, 142.64,OTHER, 86.34, 245.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4903,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4904,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.98,,OUTPCT LIMIT, 63.06,OTHER, 36.98, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4905,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 244.83,,OUTPCT LIMIT, 163.44,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4906,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4907,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 431.06,,OUTPCT LIMIT, 259.24,OTHER, 138.19, 454.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4908,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4909,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.21,,OUTPCT LIMIT, 166.91,OTHER, 118.00, 268.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4910,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4911,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 712.63,,OUTPCT LIMIT, 407.08,OTHER, 138.19, 750.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4912,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4913,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2650.70,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4914,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2650.70,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4915,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2650.70,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4916,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4917,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4918,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4919,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1046.25,,OUTPCT LIMIT, 664.89,OTHER, 483.75, 1102.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4920,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4921,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3012.05,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4922,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3012.05,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4923,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4924,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4925,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2976.00,,OUTPCT LIMIT, 1665.51,OTHER, 432.18, 3136.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4926,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4927,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2612.23,,OUTPCT LIMIT, 1439.18,OTHER, 283.82, 2752.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4928,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4929,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2951.39,,OUTPCT LIMIT, 1652.58,OTHER, 432.18, 3110.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4930,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4931,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2790.00,,OUTPCT LIMIT, 1580.48,OTHER, 485.27, 2940.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4932,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4933,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3030.47,,OUTPCT LIMIT, 1712.29,OTHER, 508.57, 3193.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4934,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4935,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3378.02,,OUTPCT LIMIT, 1894.78,OTHER, 508.57, 3559.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4936,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4937,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2965.03,,OUTPCT LIMIT, 1677.93,OTHER, 508.57, 3124.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4938,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4939,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3683.92,,OUTPCT LIMIT, 2119.80,OTHER, 779.04, 3881.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4940,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4941,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4483.32,,OUTPCT LIMIT, 2539.54,OTHER, 779.04, 4724.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4942,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4943,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4198.89,,OUTPCT LIMIT, 2390.20,OTHER, 779.04, 4424.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4944,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4945,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4946,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4947,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4948,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 388.35,,OUTPCT LIMIT, 236.81,OTHER, 138.19, 409.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4949,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4950,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 306.56,,OUTPCT LIMIT, 193.87,OTHER, 138.19, 323.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4951,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4952,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2273.19,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4953,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2273.19,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4954,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4955,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4956,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2196.29,,OUTPCT LIMIT, 1256.10,OTHER, 432.18, 2314.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4957,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4958,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1483.82,,OUTPCT LIMIT, 894.65,OTHER, 485.27, 1563.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4959,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4960,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3105.19,,OUTPCT LIMIT, 1751.53,OTHER, 508.57, 3272.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4961,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4962,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4654.37,,OUTPCT LIMIT, 2629.35,OTHER, 779.04, 4904.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4963,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4964,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1860.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4965,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1860.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4966,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1860.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4967,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4968,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4969,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4970,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 273.54,,OUTPCT LIMIT, 164.19,OTHER, 86.34, 288.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4971,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4972,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 388.13,,OUTPCT LIMIT, 224.35,OTHER, 86.34, 408.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4973,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4974,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 358.34,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4975,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 358.34,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4976,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 371.67,,OUTPCT LIMIT, 215.71,OTHER, 86.34, 391.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4977,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4978,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4979,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4980,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 244.83,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4981,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 244.83,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4982,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 244.83,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4983,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4984,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4985,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4986,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 295.74,,OUTPCT LIMIT, 175.84,OTHER, 86.34, 311.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4987,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 282.82,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4988,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 282.82,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4989,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4990,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4991,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4992,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 385.02,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4993,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 385.02,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4994,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.10,,OUTPCT LIMIT, 240.36,OTHER, 138.19, 416.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4995,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4996,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4997,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4998,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 379.27,,OUTPCT LIMIT, 219.70,OTHER, 86.34, 399.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 4999,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 369.28,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5000,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 369.28,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5001,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5002,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5003,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5004,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 354.24,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5005,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 364.23,,OUTPCT LIMIT, 211.81,OTHER, 86.34, 383.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5006,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 354.24,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5007,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5008,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5009,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5010,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 398.97,,OUTPCT LIMIT, 230.04,OTHER, 86.34, 420.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5011,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 386.51,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5012,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5013,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5014,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5015,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 400.46,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5016,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 400.46,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5017,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 412.92,,OUTPCT LIMIT, 237.37,OTHER, 86.34, 435.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5018,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5019,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5020,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5021,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 127.41,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5022,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 176.70,,OUTPCT LIMIT, 125.68,OTHER, 81.70, 186.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5023,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 127.41,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5024,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5025,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5026,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5027,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 367.91,,OUTPCT LIMIT, 213.73,OTHER, 86.34, 387.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5028,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 356.48,,OUTPCT LIMIT, 207.73,OTHER, 86.34, 375.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5029,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 356.49,,OUTPCT LIMIT, 207.74,OTHER, 86.34, 375.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5030,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5031,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5032,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5033,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 414.47,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5034,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 424.48,,OUTPCT LIMIT, 243.44,OTHER, 86.34, 447.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5035,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 414.47,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5036,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5037,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5038,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5039,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 391.53,,OUTPCT LIMIT, 238.48,OTHER, 138.19, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5040,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 379.07,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5041,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 379.07,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5042,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5043,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5044,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5045,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 380.52,,OUTPCT LIMIT, 220.36,OTHER, 86.34, 400.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5046,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 380.64,,OUTPCT LIMIT, 220.42,OTHER, 86.34, 401.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5047,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 390.64,,OUTPCT LIMIT, 225.67,OTHER, 86.34, 411.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5048,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5049,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5050,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5051,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 317.04,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5052,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 293.55,,OUTPCT LIMIT, 174.69,OTHER, 86.34, 309.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5053,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 283.56,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5054,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 283.56,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5055,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 283.56,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5056,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 283.56,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5057,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 283.56,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5058,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 283.56,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5059,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 283.56,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5060,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 283.56,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5061,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 283.56,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5062,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 283.56,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5063,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 283.56,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5064,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5065,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5066,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5067,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5068,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5069,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5070,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5071,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5072,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5073,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5074,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5075,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5076,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5077,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1759.25,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5078,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1892.10,,OUTPCT LIMIT, 1061.06,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5079,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1892.10,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5080,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1892.10,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5081,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1892.10,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5082,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1892.10,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5083,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1892.10,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5084,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 622.17,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5085,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 622.17,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5086,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1892.10,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5087,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1892.10,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5088,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 622.17,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5089,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1892.10,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5090,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1892.10,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5091,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1759.25,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5092,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5093,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5094,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5095,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5096,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5097,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5098,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5099,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5100,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5101,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5102,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5103,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5104,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5105,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5106,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2630.96,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5107,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2630.96,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5108,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5109,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5110,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5111,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1254.57,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5112,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1254.57,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5113,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5114,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5115,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1779.69,,OUTPCT LIMIT, 1055.55,OTHER, 508.57, 1875.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5116,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5117,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3069.23,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5118,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3069.23,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5119,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3069.23,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5120,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5121,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5122,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5123,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3129.14,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5124,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3129.14,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5125,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3129.14,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5126,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3129.14,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5127,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3129.14,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5128,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3129.14,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5129,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3129.14,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5130,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3129.14,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5131,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3129.14,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5132,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3129.14,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5133,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3129.14,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5134,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3129.14,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5135,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3129.14,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5136,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3129.14,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5137,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3129.14,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5138,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3129.14,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5139,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5140,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5141,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5142,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5143,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5144,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5145,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5146,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5147,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5148,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5149,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5150,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5151,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5152,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5153,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5154,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5155,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2408.93,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5156,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2408.93,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5157,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5158,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5159,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5160,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5161,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5162,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5163,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 335.06,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5164,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 335.06,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5165,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 335.06,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5166,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5167,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5168,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5169,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 323.61,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5170,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 323.61,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5171,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 323.61,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5172,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 323.61,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5173,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 323.61,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5174,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5175,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5176,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5177,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5178,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 423.32,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5179,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 336.63,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5180,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5181,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5182,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 346.46,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5183,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 346.46,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5184,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 356.46,,OUTPCT LIMIT, 208.23,OTHER, 88.46, 375.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5185,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5186,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5187,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5188,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 362.18,,OUTPCT LIMIT, 210.73,OTHER, 86.34, 381.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5189,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 350.76,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5190,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 350.76,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5191,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5192,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5193,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5194,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 449.96,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5195,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 459.96,,OUTPCT LIMIT, 274.41,OTHER, 138.19, 484.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5196,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 449.96,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5197,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5198,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5199,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5200,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 703.08,,OUTPCT LIMIT, 402.07,OTHER, 138.19, 740.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5201,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 690.29,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5202,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 690.29,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5203,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5204,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5205,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5206,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 252.94,,OUTPCT LIMIT, 153.37,OTHER, 86.34, 266.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5207,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5208,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 423.78,,OUTPCT LIMIT, 243.07,OTHER, 86.34, 446.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5209,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 413.78,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5210,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 413.78,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5211,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5212,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5213,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5214,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.98,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5215,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.98,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5216,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 159.96,,OUTPCT LIMIT, 116.89,OTHER, 73.96, 168.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5217,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5218,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5219,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5220,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 354.32,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5221,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 354.32,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5222,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 366.42,,OUTPCT LIMIT, 225.30,OTHER, 138.19, 386.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5223,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5224,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5225,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5226,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 400.83,,OUTPCT LIMIT, 243.37,OTHER, 138.19, 422.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5227,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 388.26,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5228,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 388.26,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5229,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5230,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5231,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5232,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 316.16,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5233,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 316.16,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5234,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5235,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5236,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 437.34,,OUTPCT LIMIT, 250.19,OTHER, 86.34, 460.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5237,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 427.16,,OUTPCT LIMIT, 244.84,OTHER, 86.34, 450.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5238,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 427.34,,OUTPCT LIMIT, 244.94,OTHER, 86.34, 450.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5239,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5240,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5241,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5242,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 216.69,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5243,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 216.69,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5244,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 216.69,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5245,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5246,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5247,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5248,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 289.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5249,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 289.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5250,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 289.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5251,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 289.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5252,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 289.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5253,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 289.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5254,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 289.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5255,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 289.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5256,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 179.26,OTHER, 86.34, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5257,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 289.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5258,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 289.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5259,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5260,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5261,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5262,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5263,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5264,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5265,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5266,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5267,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5268,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5269,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5270,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2131.51,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5271,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2131.51,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5272,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2131.51,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5273,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2143.65,,OUTPCT LIMIT, 1193.14,OTHER, 283.82, 2258.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5274,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2131.51,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5275,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2131.51,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5276,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2131.51,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5277,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2131.51,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5278,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2131.51,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5279,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2131.51,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5280,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2131.51,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5281,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2131.51,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5282,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2131.51,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5283,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2131.51,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5284,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5285,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5286,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5287,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5288,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5289,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5290,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5291,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5292,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5293,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5294,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5295,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5296,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5297,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5298,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2537.04,,OUTPCT LIMIT, 1435.02,OTHER, 432.18, 2673.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5299,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2524.42,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5300,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2524.42,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5301,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5302,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5303,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5304,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1254.57,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5305,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1254.57,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5306,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1254.57,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5307,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5308,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5309,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5310,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1291.77,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5311,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1291.77,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5312,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5313,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5314,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2751.81,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5315,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2751.81,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5316,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2751.81,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5317,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2751.81,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5318,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2751.81,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5319,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2751.81,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5320,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5321,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5322,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5323,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5324,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5325,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5326,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3366.95,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5327,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3366.95,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5328,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5329,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5330,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2932.97,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5331,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2932.97,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5332,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2932.98,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5333,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2932.98,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5334,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2932.97,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5335,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2932.97,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5336,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2932.97,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5337,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2932.97,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5338,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2932.97,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5339,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2932.97,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5340,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5341,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5342,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5343,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5344,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5345,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5346,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5347,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5348,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5349,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5350,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4280.71,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5351,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4280.71,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5352,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4280.71,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5353,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4280.71,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5354,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4280.71,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5355,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5356,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5357,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5358,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5359,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5360,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1860.00,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5361,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2139.00,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5362,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2139.00,,OUTPCT LIMIT, 1474.10,OTHER, 989.00, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5363,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1701.90,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5364,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1701.90,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5365,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5366,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5367,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5368,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5369,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5370,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 154.38,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5371,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 154.38,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5372,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5373,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5374,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.98,,OUTPCT LIMIT, 83.13,OTHER, 36.98, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5375,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 105.42,OTHER, 37.54, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5376,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 551.42,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5377,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 551.42,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5378,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5379,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5380,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2434.82,,OUTPCT LIMIT, 1346.03,OTHER, 283.82, 2565.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5381,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5382,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2745.01,,OUTPCT LIMIT, 1544.22,OTHER, 432.18, 2892.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5383,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5384,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3099.89,,OUTPCT LIMIT, 1743.20,OTHER, 485.27, 3266.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5385,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5386,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 5561.43,,OUTPCT LIMIT, 3113.75,OTHER, 813.20, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5387,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 330.15,,OUTPCT LIMIT, 473.04,OTHER, 156.77, 813.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5388,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3095.80,,OUTPCT LIMIT, 1743.46,OTHER, 495.38, 3262.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5389,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5390,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4844.57,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5391,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4844.57,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5392,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5393,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5394,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 5561.43,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5395,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 5561.43,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5396,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5397,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5398,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 6231.20,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5399,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 6231.20,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5400,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 6231.20,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5401,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5402,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5403,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5404,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2987.39,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5405,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2987.39,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5406,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5407,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5408,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3145.44,,OUTPCT LIMIT, 1837.06,OTHER, 779.04, 3314.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5409,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5410,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2325.00,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5411,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3764.64,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5412,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5413,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5414,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5415,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 649.14,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5416,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 649.14,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5417,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 649.14,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5418,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5419,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5420,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1021.63,,OUTPCT LIMIT, 704.06,OTHER, 472.37, 1076.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5421,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 68.02,OTHER, 37.54, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5422,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 359.35,,OUTPCT LIMIT, 248.14,OTHER, 166.15, 378.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5423,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 230.64,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5424,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 705.48,,OUTPCT LIMIT, 429.88,OTHER, 249.71, 743.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5425,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 132.91,OTHER, 37.54, 249.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5426,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2623.70,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5427,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2623.70,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5428,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5429,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5430,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 325.50,,OUTPCT LIMIT, 224.32,OTHER, 150.50, 343.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5431,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5432,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 670.06,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5433,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 670.06,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5434,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 670.06,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5435,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5436,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5437,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5438,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 504.60,,OUTPCT LIMIT, 286.59,OTHER, 90.89, 531.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5439,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5440,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 475.54,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5441,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 475.54,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5442,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 475.54,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5443,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 488.25,,OUTPCT LIMIT, 288.12,OTHER, 133.37, 514.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5444,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5445,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5446,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5447,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5448,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 894.71,,OUTPCT LIMIT, 503.49,OTHER, 141.55, 942.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5449,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5450,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 817.10,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5451,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 817.10,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5452,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 817.10,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5453,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 817.10,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5454,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 817.10,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5455,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5456,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5457,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5458,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5459,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5460,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 817.10,,OUTPCT LIMIT, 468.07,OTHER, 163.97, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5461,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 200.02,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5462,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 736.93,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5463,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 736.93,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5464,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 736.93,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5465,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 736.93,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5466,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 725.24,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5467,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5468,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5469,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5470,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5471,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5472,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 725.24,,OUTPCT LIMIT, 414.50,OTHER, 141.55, 764.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5473,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5474,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 348.75,,OUTPCT LIMIT, 214.87,OTHER, 133.37, 367.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5475,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 163.37,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5476,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 714.25,,OUTPCT LIMIT, 408.73,OTHER, 141.55, 752.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5477,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5478,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 902.45,,OUTPCT LIMIT, 507.55,OTHER, 141.55, 950.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5479,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5480,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1435.92,,OUTPCT LIMIT, 775.60,OTHER, 90.89, 1513.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5481,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5482,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 492.90,,OUTPCT LIMIT, 290.56,OTHER, 133.37, 519.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5483,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5484,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 735.28,,OUTPCT LIMIT, 419.77,OTHER, 141.55, 774.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5485,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5486,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 833.95,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5487,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 833.95,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5488,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 833.95,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5489,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5490,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5491,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5492,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 581.95,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5493,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 562.58,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5494,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5495,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5496,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 713.76,,OUTPCT LIMIT, 408.48,OTHER, 141.55, 752.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5497,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5498,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1488.00,,OUTPCT LIMIT, 813.95,OTHER, 137.10, 1568.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5499,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 940.83,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5500,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 940.83,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5501,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5502,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5503,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5504,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 333.83,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5505,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 511.50,,OUTPCT LIMIT, 300.33,OTHER, 133.37, 539.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5506,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 333.83,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5507,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 333.83,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5508,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 333.83,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5509,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 333.83,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5510,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 333.83,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5511,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 333.83,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5512,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 333.83,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5513,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5514,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5515,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5516,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5517,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5518,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5519,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5520,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5521,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5522,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 618.35,,OUTPCT LIMIT, 426.14,OTHER, 285.90, 651.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5523,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5524,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 394.87,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5525,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 394.87,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5526,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 394.87,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5527,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 332.01,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5528,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5529,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 332.01,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5530,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 332.01,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5531,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 270.63,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5532,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 270.63,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5533,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 132.06,,OUTPCT LIMIT, 91.01,OTHER, 61.06, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5534,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 172.05,,OUTPCT LIMIT, 78.82,OTHER, 21.15, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5535,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 270.63,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5536,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 270.63,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5537,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 270.63,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5538,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 270.63,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5539,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5540,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5541,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5542,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5543,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 455.70,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5544,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 380.37,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5545,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 455.70,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5546,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5547,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5548,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 270.63,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5549,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 270.63,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5550,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 270.63,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5551,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 270.63,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5552,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 558.00,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5553,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 385.95,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5554,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 385.95,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5555,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5556,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5557,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5558,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5559,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5560,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5561,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5562,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 159.03,,OUTPCT LIMIT, 116.40,OTHER, 73.53, 167.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5563,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 39.06,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5564,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 683.39,,OUTPCT LIMIT, 414.07,OTHER, 232.03, 720.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5565,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 182.28,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5566,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 326.43,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5567,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 39.06,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5568,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 39.06,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5569,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 275.28,,OUTPCT LIMIT, 154.63,OTHER, 42.36, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5570,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 326.43,,OUTPCT LIMIT, 204.30,OTHER, 138.19, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5571,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 39.06,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5572,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1187.45,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5573,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1187.45,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5574,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5575,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5576,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 923.08,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5577,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 923.08,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5578,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5579,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5580,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1298.20,,OUTPCT LIMIT, 757.92,OTHER, 320.35, 1367.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5581,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 230.15,OTHER, 99.36, 320.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5582,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1567.41,,OUTPCT LIMIT, 899.81,OTHER, 322.62, 1651.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5583,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 230.96,OTHER, 99.36, 322.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5584,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1832.10,,OUTPCT LIMIT, 1092.65,OTHER, 548.80, 1930.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5585,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 311.74,OTHER, 99.36, 548.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5586,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1453.71,,OUTPCT LIMIT, 864.03,OTHER, 423.08, 1531.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5587,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5588,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 465.00,,OUTPCT LIMIT, 344.89,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5589,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5590,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1395.00,,OUTPCT LIMIT, 830.31,OTHER, 410.92, 1470.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5591,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5592,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1915.80,,OUTPCT LIMIT, 1103.77,OTHER, 410.92, 2018.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5593,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5594,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1953.00,,OUTPCT LIMIT, 1111.16,OTHER, 359.95, 2058.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5595,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5596,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1025.33,,OUTPCT LIMIT, 624.07,OTHER, 359.95, 1080.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5597,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5598,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1117.24,,OUTPCT LIMIT, 672.34,OTHER, 360.01, 1177.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5599,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5600,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 902.10,,OUTPCT LIMIT, 559.38,OTHER, 360.01, 950.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5601,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5602,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2175.60,,OUTPCT LIMIT, 1228.06,OTHER, 360.01, 2292.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5603,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5604,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2301.29,,OUTPCT LIMIT, 1294.05,OTHER, 360.01, 2425.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5605,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5606,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1018.35,,OUTPCT LIMIT, 701.80,OTHER, 470.85, 1073.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5607,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 180.04,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5608,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1677.26,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5609,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1677.26,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5610,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5611,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5612,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3807.68,,OUTPCT LIMIT, 2267.81,OTHER, 1127.76, 4012.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5613,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5614,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1350.45,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5615,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1350.45,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5616,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5617,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5618,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1082.29,,OUTPCT LIMIT, 635.79,OTHER, 283.54, 1140.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5619,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 217.00,OTHER, 99.36, 283.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5620,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1738.01,,OUTPCT LIMIT, 984.09,OTHER, 300.36, 1831.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5621,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 223.01,OTHER, 99.36, 300.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5622,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1798.92,,OUTPCT LIMIT, 1050.06,OTHER, 443.12, 1895.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5623,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 274.00,OTHER, 99.36, 443.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5624,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 967.20,,OUTPCT LIMIT, 684.67,OTHER, 447.20, 1019.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5625,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.25,,OUTPCT LIMIT, 380.97,OTHER, 99.36, 742.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5626,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4430.52,,OUTPCT LIMIT, 2685.69,OTHER, 1509.32, 4668.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5627,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 372.00,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5628,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4588.62,,OUTPCT LIMIT, 2768.70,OTHER, 1509.32, 4835.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5629,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 372.00,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5630,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 56.35,,OUTPCT LIMIT, 34.30,OTHER, 19.78, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5631,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 56.35,,OUTPCT LIMIT, 32.49,OTHER, 12.18, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5632,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 578.46,,OUTPCT LIMIT, 398.65,OTHER, 267.46, 609.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5633,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 130.06,,OUTPCT LIMIT, 70.69,OTHER, 10.09, 137.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5634,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 225.76,,OUTPCT LIMIT, 122.16,OTHER, 15.20, 237.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5635,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 177.14,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5636,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 177.14,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5637,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 153.45,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5638,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 153.45,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5639,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 265.72,,OUTPCT LIMIT, 155.85,OTHER, 68.59, 280.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5640,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 145.09,,OUTPCT LIMIT, 78.98,OTHER, 11.76, 152.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5641,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 121.83,,OUTPCT LIMIT, 69.30,OTHER, 22.37, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5642,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 415.71,,OUTPCT LIMIT, 229.30,OTHER, 46.28, 438.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5643,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 163.92,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5644,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 155.87,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5645,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 93.01,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5646,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 93.01,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5647,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 143.84,,OUTPCT LIMIT, 80.17,OTHER, 19.50, 151.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5648,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 89.86,,OUTPCT LIMIT, 54.61,OTHER, 31.20, 94.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5649,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 143.76,,OUTPCT LIMIT, 80.03,OTHER, 19.08, 151.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5650,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 142.13,,OUTPCT LIMIT, 79.17,OTHER, 19.08, 149.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5651,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 117.48,,OUTPCT LIMIT, 63.95,OTHER, 9.52, 123.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5652,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 43.71,,OUTPCT LIMIT, 28.28,OTHER, 20.21, 46.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5653,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 150.73,,OUTPCT LIMIT, 83.69,OTHER, 19.08, 158.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5654,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 91.84,,OUTPCT LIMIT, 53.47,OTHER, 22.03, 96.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5655,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 143.35,,OUTPCT LIMIT, 79.81,OTHER, 19.08, 151.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5656,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 76.06,,OUTPCT LIMIT, 44.64,OTHER, 19.78, 80.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5657,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 268.93,,OUTPCT LIMIT, 145.91,OTHER, 19.78, 283.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5658,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 114.11,,OUTPCT LIMIT, 64.76,OTHER, 20.36, 120.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5659,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 223.31,,OUTPCT LIMIT, 121.34,OTHER, 17.16, 235.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5660,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 152.58,,OUTPCT LIMIT, 84.76,OTHER, 19.50, 160.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5661,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 241.77,,OUTPCT LIMIT, 134.69,OTHER, 32.53, 254.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5662,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 160.96,,OUTPCT LIMIT, 90.91,OTHER, 26.84, 169.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5663,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 177.02,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5664,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 23.25,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5665,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 37.20,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5666,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 37.20,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5667,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 243.55,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5668,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 274.35,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5669,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 157.17,,OUTPCT LIMIT, 108.31,OTHER, 72.67, 165.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5670,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 139.50,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5671,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 70.68,,OUTPCT LIMIT, 48.71,OTHER, 32.68, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5672,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 261.12,,OUTPCT LIMIT, 179.95,OTHER, 120.73, 275.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5673,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 166.33,,OUTPCT LIMIT, 114.63,OTHER, 76.91, 175.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5674,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 37.97,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5675,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 69.75,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5676,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 37.97,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5677,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 37.97,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5678,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 131.13,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5679,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 98.48,,OUTPCT LIMIT, 67.87,OTHER, 45.53, 103.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5680,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 147.87,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5681,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 147.87,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5682,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 147.87,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5683,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 125.55,,OUTPCT LIMIT, 86.52,OTHER, 58.05, 132.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5684,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.98,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5685,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 270.63,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5686,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 64.37,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5687,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 64.37,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5688,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 64.37,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5689,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 38.40,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5690,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 38.40,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5691,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 38.40,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5692,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 12.09,,OUTPCT LIMIT, 7.12,OTHER, 3.24, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5693,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 13.95,,OUTPCT LIMIT, 8.07,OTHER, 3.12, 14.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5694,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 58.87,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5695,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 58.87,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5696,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 138.57,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5697,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 138.57,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5698,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 229.38,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5699,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 229.38,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5700,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 457.56,,OUTPCT LIMIT, 262.66,OTHER, 94.12, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5701,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 757.15,,OUTPCT LIMIT, 428.98,OTHER, 131.99, 797.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5702,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 188.18,,OUTPCT LIMIT, 129.68,OTHER, 87.01, 198.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5703,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 355.26,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5704,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 355.26,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5705,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 98.27,,OUTPCT LIMIT, 53.15,OTHER, 6.50, 103.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5706,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 68.76,,OUTPCT LIMIT, 38.90,OTHER, 11.76, 72.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5707,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 254.43,,OUTPCT LIMIT, 146.83,OTHER, 55.61, 268.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5708,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 35.11,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5709,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 35.11,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5710,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 49.99,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5711,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 49.99,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5712,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 111.60,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5713,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 111.60,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5714,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 90.55,,OUTPCT LIMIT, 50.88,OTHER, 13.98, 95.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5715,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 126.56,,OUTPCT LIMIT, 71.06,OTHER, 19.36, 133.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5716,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 199.79,,OUTPCT LIMIT, 109.86,OTHER, 20.82, 210.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5717,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 141.72,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5718,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 141.72,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5719,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 110.67,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5720,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 110.67,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5721,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 92.50,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5722,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 92.50,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5723,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 172.05,,OUTPCT LIMIT, 100.38,OTHER, 42.16, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5724,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 211.19,,OUTPCT LIMIT, 121.92,OTHER, 46.34, 222.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5725,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 81.84,,OUTPCT LIMIT, 50.20,OTHER, 30.37, 86.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5726,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.14,,OUTPCT LIMIT, 116.31,OTHER, 27.31, 220.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5727,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 88.35,,OUTPCT LIMIT, 49.78,OTHER, 14.24, 93.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5728,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 110.26,,OUTPCT LIMIT, 63.44,OTHER, 23.30, 116.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5729,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 65.97,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5730,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 65.97,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5731,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 59.71,,OUTPCT LIMIT, 33.07,OTHER, 7.22, 62.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5732,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 33.95,,OUTPCT LIMIT, 19.33,OTHER, 6.31, 35.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5733,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 60.61,,OUTPCT LIMIT, 33.34,OTHER, 6.38, 63.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5734,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 56.73,OTHER, 22.92, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5735,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 217.10,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5736,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 231.57,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5737,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 217.10,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5738,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 218.01,,OUTPCT LIMIT, 123.66,OTHER, 38.58, 229.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5739,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 61.54,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5740,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 61.54,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5741,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 61.54,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5742,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 122.94,,OUTPCT LIMIT, 69.24,OTHER, 19.70, 129.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5743,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 91.22,,OUTPCT LIMIT, 49.97,OTHER, 8.69, 96.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5744,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 76.26,,OUTPCT LIMIT, 44.47,OTHER, 18.58, 80.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5745,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 116.02,,OUTPCT LIMIT, 65.14,OTHER, 17.74, 122.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5746,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 153.78,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5747,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 153.78,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5748,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 101.37,,OUTPCT LIMIT, 59.01,OTHER, 24.29, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5749,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 226.08,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5750,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 228.24,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5751,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 100.51,,OUTPCT LIMIT, 56.46,OTHER, 15.47, 105.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5752,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 22.32,,OUTPCT LIMIT, 13.69,OTHER, 8.28, 23.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5753,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 132.28,,OUTPCT LIMIT, 73.71,OTHER, 17.87, 139.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5754,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 156.17,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5755,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 156.17,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5756,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 115.65,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5757,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 115.65,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5758,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 346.48,,OUTPCT LIMIT, 190.19,OTHER, 34.69, 365.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5759,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 391.86,,OUTPCT LIMIT, 214.01,OTHER, 34.69, 412.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5760,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 86.19,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5761,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 86.19,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5762,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 70.68,,OUTPCT LIMIT, 41.70,OTHER, 19.28, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5763,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 106.21,,OUTPCT LIMIT, 59.73,OTHER, 16.63, 111.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5764,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 56.89,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5765,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 56.89,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5766,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 56.89,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5767,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 71.11,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5768,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 71.11,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5769,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 171.84,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5770,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 171.84,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5771,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 78.12,,OUTPCT LIMIT, 45.06,OTHER, 16.97, 82.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5772,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 140.92,,OUTPCT LIMIT, 76.21,OTHER, 9.31, 148.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5773,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 127.72,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5774,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 127.72,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5775,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 131.44,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5776,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 131.44,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5777,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 226.18,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5778,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 226.18,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5779,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 166.51,,OUTPCT LIMIT, 93.87,OTHER, 27.06, 175.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5780,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 239.79,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5781,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 239.79,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5782,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 138.57,,OUTPCT LIMIT, 83.83,OTHER, 46.51, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5783,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 124.62,,OUTPCT LIMIT, 73.72,OTHER, 34.82, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5784,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 127.41,,OUTPCT LIMIT, 75.45,OTHER, 35.93, 134.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5785,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 216.46,,OUTPCT LIMIT, 121.64,OTHER, 33.53, 228.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5786,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 128.40,,OUTPCT LIMIT, 69.17,OTHER, 7.34, 135.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5787,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 226.46,,OUTPCT LIMIT, 124.67,OTHER, 24.19, 238.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5788,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 136.71,,OUTPCT LIMIT, 76.46,OTHER, 19.63, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5789,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 126.54,,OUTPCT LIMIT, 71.48,OTHER, 21.17, 133.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5790,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 394.10,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5791,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 144.16,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5792,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 98.36,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5793,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 98.36,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5794,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 98.36,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5795,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 112.97,,OUTPCT LIMIT, 64.96,OTHER, 23.70, 119.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5796,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 61.38,,OUTPCT LIMIT, 34.98,OTHER, 11.54, 64.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5797,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 370.59,,OUTPCT LIMIT, 203.52,OTHER, 37.54, 390.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5798,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 106.02,,OUTPCT LIMIT, 61.71,OTHER, 25.39, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5799,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 46.27,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5800,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 46.27,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5801,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 46.27,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5802,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 51.36,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5803,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 51.36,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5804,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 51.36,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5805,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 24.37,,OUTPCT LIMIT, 14.14,OTHER, 5.66, 25.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5806,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 119.66,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5807,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 119.66,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5808,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 103.96,,OUTPCT LIMIT, 57.91,OTHER, 13.97, 109.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5809,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 66.80,,OUTPCT LIMIT, 37.55,OTHER, 10.37, 70.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5810,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 168.28,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5811,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 168.28,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5812,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 167.92,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5813,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 167.92,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5814,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 119.48,,OUTPCT LIMIT, 67.05,OTHER, 18.12, 125.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5815,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 128.34,,OUTPCT LIMIT, 74.92,OTHER, 31.62, 135.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5816,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 85.65,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5817,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 85.65,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5818,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 85.65,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5819,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 178.43,,OUTPCT LIMIT, 99.83,OTHER, 25.80, 188.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5820,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 279.93,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5821,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 246.80,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5822,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 246.80,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5823,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 246.80,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5824,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 246.80,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5825,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 246.80,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5826,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 275.85,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5827,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 166.53,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5828,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 256.76,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5829,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 39.99,,OUTPCT LIMIT, 25.93,OTHER, 18.49, 42.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5830,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 124.02,,OUTPCT LIMIT, 69.04,OTHER, 16.46, 130.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5831,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.35,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5832,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.35,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5833,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.35,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5834,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.09,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5835,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.09,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5836,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.09,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5837,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.09,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5838,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 125.83,,OUTPCT LIMIT, 70.04,OTHER, 16.66, 132.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5839,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 80.41,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5840,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 105.95,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5841,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 154.38,,OUTPCT LIMIT, 85.45,OTHER, 18.42, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5842,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 118.11,,OUTPCT LIMIT, 68.77,OTHER, 28.37, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5843,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 96.39,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5844,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 96.39,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5845,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 110.68,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5846,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 110.68,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5847,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 253.63,,OUTPCT LIMIT, 149.05,OTHER, 66.68, 267.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5848,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 60.45,,OUTPCT LIMIT, 43.46,OTHER, 27.95, 63.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5849,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 75.05,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5850,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 75.05,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5851,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 73.02,,OUTPCT LIMIT, 40.64,OTHER, 9.65, 76.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5852,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 372.85,,OUTPCT LIMIT, 204.04,OTHER, 34.72, 392.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5853,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 98.88,,OUTPCT LIMIT, 57.49,OTHER, 23.41, 104.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5854,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 292.83,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5855,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 292.83,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5856,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 155.00,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5857,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 113.01,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5858,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 203.67,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5859,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 203.67,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5860,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 197.47,,OUTPCT LIMIT, 110.95,OTHER, 30.54, 208.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5861,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 98.85,,OUTPCT LIMIT, 54.17,OTHER, 9.52, 104.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5862,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 80.20,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5863,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 80.20,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5864,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 154.63,,OUTPCT LIMIT, 86.15,OTHER, 20.81, 162.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5865,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 253.01,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5866,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 253.01,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5867,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 70.68,,OUTPCT LIMIT, 43.75,OTHER, 27.89, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5868,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 342.58,,OUTPCT LIMIT, 186.61,OTHER, 28.27, 361.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5869,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.98,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5870,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 87.98,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5871,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 63.93,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5872,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 63.93,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5873,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 51.88,,OUTPCT LIMIT, 28.87,OTHER, 6.85, 54.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5874,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 23.25,,OUTPCT LIMIT, 13.83,OTHER, 6.82, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5875,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 77.25,,OUTPCT LIMIT, 45.56,OTHER, 21.01, 81.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5876,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 162.97,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5877,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 162.97,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5878,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 178.00,,OUTPCT LIMIT, 102.79,OTHER, 39.19, 187.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5879,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 172.40,,OUTPCT LIMIT, 97.17,OTHER, 27.91, 181.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5880,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 153.74,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5881,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 165.86,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5882,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 165.86,,OUTPCT LIMIT, 93.39,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5883,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 44.57,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5884,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 44.57,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5885,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 107.76,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5886,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 107.76,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5887,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 107.76,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5888,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 76.07,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5889,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 76.07,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5890,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.44,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5891,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 370.22,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5892,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 164.48,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5893,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 141.84,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5894,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 374.20,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5895,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 242.25,,OUTPCT LIMIT, 136.35,OTHER, 38.44, 255.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5896,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 178.34,,OUTPCT LIMIT, 103.27,OTHER, 40.46, 187.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5897,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 132.06,,OUTPCT LIMIT, 76.88,OTHER, 31.67, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5898,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 327.36,,OUTPCT LIMIT, 178.83,OTHER, 29.15, 344.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5899,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 154.22,,OUTPCT LIMIT, 88.43,OTHER, 31.30, 162.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5900,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 54.03,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5901,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 54.03,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5902,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 84.04,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5903,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 84.04,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5904,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 17.25,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5905,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 330.31,,OUTPCT LIMIT, 180.72,OTHER, 30.61, 348.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5906,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 571.69,,OUTPCT LIMIT, 302.95,OTHER, 11.66, 602.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5907,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 139.34,,OUTPCT LIMIT, 81.90,OTHER, 36.67, 146.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5908,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 217.64,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5909,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 217.64,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5910,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 217.64,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5911,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 217.64,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5912,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 151.44,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5913,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 151.44,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5914,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 193.97,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5915,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 193.97,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5916,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 96.97,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5917,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 96.97,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5918,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 138.76,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5919,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 138.76,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5920,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 138.76,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5921,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 89.28,,OUTPCT LIMIT, 51.95,OTHER, 21.29, 94.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5922,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 129.07,,OUTPCT LIMIT, 73.53,OTHER, 24.19, 136.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5923,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 260.40,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5924,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 260.40,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5925,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 85.56,,OUTPCT LIMIT, 49.79,OTHER, 20.42, 90.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5926,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 69.59,,OUTPCT LIMIT, 38.32,OTHER, 7.46, 73.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5927,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 65.08,,OUTPCT LIMIT, 35.99,OTHER, 7.63, 68.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5928,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 103.10,,OUTPCT LIMIT, 58.51,OTHER, 18.37, 108.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5929,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 70.78,,OUTPCT LIMIT, 39.13,OTHER, 8.27, 74.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5930,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 141.97,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5931,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 141.97,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5932,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 139.20,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5933,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 139.20,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5934,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 231.37,,OUTPCT LIMIT, 126.89,OTHER, 22.69, 243.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5935,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 149.92,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5936,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 149.92,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5937,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 71.94,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5938,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 71.94,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5939,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 71.94,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5940,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 39.41,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5941,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 39.41,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5942,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 57.75,,OUTPCT LIMIT, 31.87,OTHER, 6.50, 60.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5943,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 71.15,,OUTPCT LIMIT, 39.10,OTHER, 7.32, 74.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5944,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 137.80,,OUTPCT LIMIT, 76.33,OTHER, 16.72, 145.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5945,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 188.56,,OUTPCT LIMIT, 103.71,OTHER, 19.75, 198.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5946,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 100.51,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5947,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 100.51,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5948,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 100.51,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5949,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 149.45,,OUTPCT LIMIT, 85.61,OTHER, 29.96, 157.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5950,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 174.98,,OUTPCT LIMIT, 97.04,OTHER, 21.67, 184.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5951,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 78.52,,OUTPCT LIMIT, 42.88,OTHER, 6.94, 82.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5952,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 80.94,,OUTPCT LIMIT, 43.80,OTHER, 5.47, 85.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5953,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 32.45,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5954,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 32.45,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5955,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 39.32,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5956,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 39.32,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5957,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5958,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.90,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5959,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 80.93,,OUTPCT LIMIT, 44.71,OTHER, 9.31, 85.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5960,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 69.11,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5961,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 69.11,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5962,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 36.27,,OUTPCT LIMIT, 19.92,OTHER, 3.66, 38.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5963,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 59.21,,OUTPCT LIMIT, 32.63,OTHER, 6.46, 62.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5964,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 172.62,,OUTPCT LIMIT, 96.77,OTHER, 25.78, 181.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5965,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 231.28,,OUTPCT LIMIT, 129.31,OTHER, 33.04, 243.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5966,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 240.87,,OUTPCT LIMIT, 130.54,OTHER, 17.06, 253.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5967,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 178.25,,OUTPCT LIMIT, 98.34,OTHER, 19.93, 187.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5968,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 159.50,,OUTPCT LIMIT, 89.00,OTHER, 22.06, 168.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5969,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 180.42,,OUTPCT LIMIT, 98.22,OTHER, 14.66, 190.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5970,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.71,,OUTPCT LIMIT, 54.63,OTHER, 13.99, 102.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5971,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 121.83,,OUTPCT LIMIT, 70.40,OTHER, 27.00, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5972,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 54.18,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5973,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 53.83,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5974,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 54.18,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5975,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 24.18,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5976,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 24.18,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5977,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 24.18,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5978,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 24.18,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5979,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 76.45,,OUTPCT LIMIT, 41.60,OTHER, 6.14, 80.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5980,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 48.36,,OUTPCT LIMIT, 26.32,OTHER, 3.89, 50.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5981,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 65.63,,OUTPCT LIMIT, 36.35,OTHER, 7.93, 69.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5982,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 158.10,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5983,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 69.64,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5984,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 140.91,,OUTPCT LIMIT, 76.67,OTHER, 11.26, 148.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5985,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1105.17,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5986,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 300.39,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5987,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5988,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5989,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5990,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5991,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5992,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5993,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5994,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5995,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5996,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5997,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5998,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 5999,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6000,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6001,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6002,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6003,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6004,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6005,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6006,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6007,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6008,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6009,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6010,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6011,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6012,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6013,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6014,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6015,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6016,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6017,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6018,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6019,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6020,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6021,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6022,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6023,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 57.33,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6024,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6025,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6026,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6027,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6028,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 29.85,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6029,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6030,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6031,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6032,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6033,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6034,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6035,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6036,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6037,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6038,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6039,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6040,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6041,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6042,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6043,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6044,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6045,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6046,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6047,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 348.52,,OUTPCT LIMIT, 189.29,OTHER, 26.45, 367.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6048,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 212.79,,OUTPCT LIMIT, 115.17,OTHER, 14.46, 224.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6049,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 123.97,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6050,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 209.51,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6051,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 85.87,,OUTPCT LIMIT, 48.91,OTHER, 16.07, 90.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6052,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 81.38,,OUTPCT LIMIT, 45.23,OTHER, 10.51, 85.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6053,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 29.15,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6054,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 29.15,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6055,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 104.39,,OUTPCT LIMIT, 59.25,OTHER, 18.65, 110.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6056,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 162.37,,OUTPCT LIMIT, 93.98,OTHER, 36.65, 171.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6057,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 245.01,,OUTPCT LIMIT, 137.37,OTHER, 36.65, 258.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6058,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 138.94,,OUTPCT LIMIT, 78.46,OTHER, 23.14, 146.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6059,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 121.14,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6060,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 120.83,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6061,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 134.69,,OUTPCT LIMIT, 77.69,OTHER, 29.26, 141.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6062,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 111.88,,OUTPCT LIMIT, 63.19,OTHER, 18.65, 117.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6063,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 111.72,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6064,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 121.28,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6065,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 131.55,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6066,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 131.55,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6067,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 131.55,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6068,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 131.55,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6069,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 131.71,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6070,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 131.55,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6071,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 112.39,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6072,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 104.77,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6073,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 147.87,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6074,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 226.15,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6075,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 218.32,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6076,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 23.25,,OUTPCT LIMIT, 15.65,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6077,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 138.61,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6078,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 142.51,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6079,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 148.53,,OUTPCT LIMIT, 85.12,OTHER, 29.96, 156.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6080,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 183.43,,OUTPCT LIMIT, 103.45,OTHER, 29.96, 193.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6081,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 125.83,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6082,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 327.83,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6083,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 92.87,,OUTPCT LIMIT, 50.54,OTHER, 7.46, 97.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6084,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 154.67,,OUTPCT LIMIT, 88.87,OTHER, 32.17, 162.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6085,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 112.53,,OUTPCT LIMIT, 66.43,OTHER, 30.83, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6086,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 99.52,,OUTPCT LIMIT, 57.43,OTHER, 21.72, 104.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6087,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 489.41,,OUTPCT LIMIT, 265.06,OTHER, 33.95, 515.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6088,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 136.71,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6089,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 136.71,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6090,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 188.33,,OUTPCT LIMIT, 111.82,OTHER, 54.34, 198.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6091,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 304.95,,OUTPCT LIMIT, 176.22,OTHER, 67.64, 321.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6092,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 150.20,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6093,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 150.20,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6094,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 124.62,,OUTPCT LIMIT, 68.73,OTHER, 13.84, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6095,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 151.70,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6096,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 195.30,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6097,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 124.62,,OUTPCT LIMIT, 70.10,OTHER, 19.60, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6098,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 85.54,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6099,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 85.54,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6100,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 324.57,,OUTPCT LIMIT, 191.67,OTHER, 89.24, 342.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6101,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 17.39,,OUTPCT LIMIT, 12.31,OTHER, 8.04, 18.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6102,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 32.47,,OUTPCT LIMIT, 18.56,OTHER, 6.34, 34.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6103,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 59.13,,OUTPCT LIMIT, 36.21,OTHER, 21.67, 62.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6104,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 98.58,,OUTPCT LIMIT, 55.25,OTHER, 14.66, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6105,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 68.00,,OUTPCT LIMIT, 40.13,OTHER, 18.58, 71.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6106,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 118.11,,OUTPCT LIMIT, 66.54,OTHER, 19.00, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6107,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 157.20,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6108,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 157.20,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6109,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 157.20,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6110,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 43.10,,OUTPCT LIMIT, 26.75,OTHER, 17.29, 45.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6111,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 90.14,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6112,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 241.80,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6113,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 87.42,,OUTPCT LIMIT, 50.83,OTHER, 20.72, 92.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6114,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 101.37,,OUTPCT LIMIT, 59.00,OTHER, 24.26, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6115,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 112.77,,OUTPCT LIMIT, 64.46,OTHER, 22.02, 118.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6116,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 101.47,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6117,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 101.47,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6118,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 170.17,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6119,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 102.42,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6120,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 102.42,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6121,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 114.39,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6122,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 114.39,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6123,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 73.47,,OUTPCT LIMIT, 43.51,OTHER, 20.72, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6124,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 82.19,,OUTPCT LIMIT, 47.68,OTHER, 19.00, 86.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6125,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 98.58,,OUTPCT LIMIT, 58.39,OTHER, 27.86, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6126,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 138.53,,OUTPCT LIMIT, 77.47,OTHER, 19.86, 145.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6127,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 110.08,,OUTPCT LIMIT, 62.50,OTHER, 19.74, 116.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6128,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 81.16,,OUTPCT LIMIT, 46.75,OTHER, 17.35, 85.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6129,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 70.68,,OUTPCT LIMIT, 41.14,OTHER, 16.94, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6130,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 120.74,,OUTPCT LIMIT, 67.08,OTHER, 15.47, 127.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6131,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 88.14,,OUTPCT LIMIT, 50.52,OTHER, 17.84, 92.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6132,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 46.31,,OUTPCT LIMIT, 28.18,OTHER, 16.21, 48.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6133,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 91.55,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6134,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 91.55,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6135,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 69.75,,OUTPCT LIMIT, 41.16,OTHER, 19.07, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6136,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 78.43,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6137,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 78.43,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6138,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 78.43,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6139,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 81.14,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6140,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 83.93,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6141,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 83.93,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6142,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 85.40,,OUTPCT LIMIT, 49.38,OTHER, 19.07, 89.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6143,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 144.16,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6144,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 144.16,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6145,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 680.56,,OUTPCT LIMIT, 361.76,OTHER, 18.55, 717.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6146,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 298.53,,OUTPCT LIMIT, 161.64,OTHER, 20.54, 314.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6147,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 260.19,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6148,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 260.19,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6149,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 142.20,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6150,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 142.20,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6151,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 142.20,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6152,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 222.27,,OUTPCT LIMIT, 152.44,OTHER, 102.77, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6153,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 400.70,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6154,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 400.70,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6155,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 400.70,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6156,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 152.20,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6157,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 152.20,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6158,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 152.20,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6159,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 152.20,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6160,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 152.20,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6161,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 276.31,,OUTPCT LIMIT, 146.86,OTHER, 7.46, 291.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6162,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 102.30,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6163,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 102.30,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6164,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 102.30,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6165,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 84.70,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6166,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 80.50,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6167,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 84.70,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6168,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 400.70,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6169,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 400.70,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6170,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 364.10,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6171,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 129.74,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6172,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 129.74,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6173,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 552.62,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6174,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 552.62,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6175,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 552.62,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6176,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 552.62,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6177,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 552.62,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6178,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 552.62,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6179,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 129.74,,OUTPCT LIMIT, 76.50,OTHER, 35.20, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6180,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 242.73,,OUTPCT LIMIT, 149.18,OTHER, 91.25, 255.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6181,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 148.30,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6182,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 148.30,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6183,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 52.42,,OUTPCT LIMIT, 30.76,OTHER, 13.60, 55.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6184,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 132.71,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6185,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 132.71,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6186,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 142.87,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6187,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 142.87,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6188,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 145.16,,OUTPCT LIMIT, 78.99,OTHER, 11.64, 152.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6189,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 83.80,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6190,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 83.80,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6191,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 83.80,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6192,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 73.68,,OUTPCT LIMIT, 40.96,OTHER, 9.55, 77.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6193,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.82,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6194,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.82,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6195,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.82,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6196,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 151.39,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6197,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 151.39,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6198,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 136.86,,OUTPCT LIMIT, 74.74,OTHER, 12.11, 144.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6199,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 166.27,,OUTPCT LIMIT, 91.00,OTHER, 15.55, 175.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6200,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 124.29,,OUTPCT LIMIT, 68.31,OTHER, 12.82, 130.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6201,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 30.69,,OUTPCT LIMIT, 17.74,OTHER, 6.84, 32.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6202,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 38.90,,OUTPCT LIMIT, 22.99,OTHER, 10.78, 40.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6203,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 53.94,,OUTPCT LIMIT, 29.95,OTHER, 6.84, 56.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6204,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 75.13,,OUTPCT LIMIT, 42.41,OTHER, 12.46, 79.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6205,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 52.63,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6206,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 49.00,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6207,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 49.00,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6208,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 49.19,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6209,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 49.19,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6210,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 69.13,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6211,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 69.13,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6212,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 50.08,,OUTPCT LIMIT, 28.29,OTHER, 8.38, 52.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6213,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 118.11,,OUTPCT LIMIT, 68.72,OTHER, 28.16, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6214,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 562.37,,OUTPCT LIMIT, 299.39,OTHER, 17.26, 592.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6215,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 70.70,,OUTPCT LIMIT, 40.67,OTHER, 14.88, 74.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6216,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 74.51,,OUTPCT LIMIT, 43.08,OTHER, 16.61, 78.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6217,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 222.27,,OUTPCT LIMIT, 121.25,OTHER, 19.08, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6218,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 118.11,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6219,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 179.49,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6220,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 179.50,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6221,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 179.49,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6222,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 179.49,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6223,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 179.49,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6224,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 350.75,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6225,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 350.75,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6226,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 146.13,,OUTPCT LIMIT, 100.71,OTHER, 67.57, 153.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6227,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 393.83,,OUTPCT LIMIT, 221.47,OTHER, 61.69, 415.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6228,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 122.66,,OUTPCT LIMIT, 76.43,OTHER, 50.53, 129.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6229,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 449.19,,OUTPCT LIMIT, 265.03,OTHER, 122.54, 473.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6230,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 179.50,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6231,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 139.50,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6232,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 139.50,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6233,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 576.66,,OUTPCT LIMIT, 445.68,OTHER, 266.63, 607.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6234,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 93.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6235,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 93.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6236,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 93.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6237,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 346.54,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6238,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 346.54,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6239,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6240,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 307.83,,OUTPCT LIMIT, 173.66,OTHER, 50.53, 324.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6241,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 118.11,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6242,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 162.94,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6243,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 569.10,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6244,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 251.07,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6245,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 251.07,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6246,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 107.76,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6247,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 107.76,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6248,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 73.47,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6249,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 73.47,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6250,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 73.47,,OUTPCT LIMIT, 44.25,OTHER, 23.81, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6251,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 23.25,,OUTPCT LIMIT, 17.88,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6252,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 180.22,,OUTPCT LIMIT, 100.14,OTHER, 23.14, 189.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6253,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1356.87,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6254,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1356.87,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6255,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 96.72,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6256,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 96.72,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6257,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 516.15,,OUTPCT LIMIT, 294.34,OTHER, 97.97, 543.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6258,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6259,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6260,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 28.83,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6261,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 28.83,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6262,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 104.54,,OUTPCT LIMIT, 56.81,OTHER, 8.06, 110.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6263,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 71.35,,OUTPCT LIMIT, 39.98,OTHER, 10.56, 75.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6264,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 71.61,,OUTPCT LIMIT, 41.73,OTHER, 17.35, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6265,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 5517.16,,OUTPCT LIMIT, 3802.17,OTHER, 2550.94, 5813.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6266,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 104.77,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6267,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 104.77,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6268,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 27.44,,OUTPCT LIMIT, 23.30,OTHER, 12.69, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6269,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 55.34,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6270,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 27.67,,OUTPCT LIMIT, 23.42,OTHER, 12.79, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6271,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 119.97,,OUTPCT LIMIT, 82.68,OTHER, 55.47, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6272,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6273,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 142.29,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6274,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 142.29,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6275,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 129.22,,OUTPCT LIMIT, 89.06,OTHER, 59.75, 136.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6276,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 46.50,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6277,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 46.50,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6278,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 551.85,,OUTPCT LIMIT, 356.50,OTHER, 255.16, 581.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6279,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1153.00,,OUTPCT LIMIT, 687.64,OTHER, 345.38, 1214.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6280,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 292.49,,OUTPCT LIMIT, 201.57,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6281,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6282,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6283,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.05,,OUTPCT LIMIT, 60.00,OTHER, 36.55, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6284,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 47.85,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6285,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 47.85,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6286,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6287,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6288,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6289,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 10.23,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6290,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 10.23,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6291,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 10.23,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6292,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 10.23,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6293,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 74.16,,OUTPCT LIMIT, 51.11,OTHER, 34.29, 78.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6294,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 127.14,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6295,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 127.14,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6296,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6297,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 146.75,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6298,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 146.75,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6299,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6300,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6301,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 158.95,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6302,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 158.95,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6303,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 9.30,,OUTPCT LIMIT, 12.78,OTHER, 4.30, 33.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6304,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 30.75,,OUTPCT LIMIT, 17.36,OTHER, 5.09, 32.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6305,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 282.64,,OUTPCT LIMIT, 184.48,OTHER, 130.68, 297.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6306,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 316.67,,OUTPCT LIMIT, 202.35,OTHER, 146.42, 333.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6307,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 137.58,,OUTPCT LIMIT, 99.37,OTHER, 63.61, 144.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6308,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 141.43,,OUTPCT LIMIT, 88.44,OTHER, 59.56, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6309,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 182.16,,OUTPCT LIMIT, 131.72,OTHER, 84.22, 191.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6310,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 179.09,,OUTPCT LIMIT, 117.05,OTHER, 82.81, 188.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6311,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 273.62,,OUTPCT LIMIT, 179.75,OTHER, 126.51, 288.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6312,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 236.73,,OUTPCT LIMIT, 158.52,OTHER, 109.46, 249.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6313,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 285.93,,OUTPCT LIMIT, 186.21,OTHER, 132.20, 301.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6314,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 136.81,,OUTPCT LIMIT, 83.96,OTHER, 50.93, 144.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6315,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 220.60,,OUTPCT LIMIT, 167.44,OTHER, 102.00, 232.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6316,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 229.81,,OUTPCT LIMIT, 172.28,OTHER, 106.26, 242.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6317,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 55.34,,OUTPCT LIMIT, 49.86,OTHER, 25.59, 87.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6318,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 230.58,,OUTPCT LIMIT, 141.43,OTHER, 85.51, 242.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6319,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 98.23,,OUTPCT LIMIT, 69.71,OTHER, 45.42, 103.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6320,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 260.56,,OUTPCT LIMIT, 177.65,OTHER, 120.47, 274.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6321,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 283.04,,OUTPCT LIMIT, 189.46,OTHER, 130.87, 298.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6322,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 455.35,,OUTPCT LIMIT, 279.93,OTHER, 171.54, 479.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6323,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 426.91,,OUTPCT LIMIT, 265.00,OTHER, 171.54, 449.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6324,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 233.98,,OUTPCT LIMIT, 149.90,OTHER, 108.18, 246.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6325,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 297.18,,OUTPCT LIMIT, 167.02,OTHER, 46.09, 313.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6326,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 124.03,,OUTPCT LIMIT, 76.10,OTHER, 46.09, 130.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6327,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 259.72,,OUTPCT LIMIT, 147.35,OTHER, 46.09, 273.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6328,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 376.37,,OUTPCT LIMIT, 227.22,OTHER, 124.32, 396.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6329,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 506.39,,OUTPCT LIMIT, 295.49,OTHER, 124.32, 533.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6330,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 161.49,,OUTPCT LIMIT, 114.40,OTHER, 74.67, 170.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6331,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 239.74,,OUTPCT LIMIT, 155.48,OTHER, 110.85, 252.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6332,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 37.15,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6333,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 37.15,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6334,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 37.15,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6335,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 18.18,,OUTPCT LIMIT, 36.72,OTHER, 8.41, 114.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6336,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 342.57,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6337,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 342.57,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6338,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 845.96,,OUTPCT LIMIT, 526.62,OTHER, 346.21, 891.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6339,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 290.83,OTHER, 143.52, 346.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6340,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 309.94,,OUTPCT LIMIT, 266.67,OTHER, 147.17, 326.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6341,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 286.44,,OUTPCT LIMIT, 162.12,OTHER, 49.24, 301.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6342,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 230.64,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6343,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 230.64,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6344,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 294.81,,OUTPCT LIMIT, 166.97,OTHER, 51.13, 310.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6345,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 81.48,,OUTPCT LIMIT, 54.96,OTHER, 37.67, 85.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6346,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 141.43,,OUTPCT LIMIT, 86.43,OTHER, 51.13, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6347,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1512.81,,OUTPCT LIMIT, 950.56,OTHER, 656.16, 1594.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6348,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 375.80,OTHER, 121.44, 656.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6349,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 864.90,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6350,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 864.90,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6351,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6352,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6353,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1025.11,,OUTPCT LIMIT, 591.97,OTHER, 225.62, 1080.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6354,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6355,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 433.09,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6356,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 433.09,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6357,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 197.77,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6358,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 971.17,,OUTPCT LIMIT, 563.65,OTHER, 225.62, 1023.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6359,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6360,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 151.59,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6361,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 151.59,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6362,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6363,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6364,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 465.00,,OUTPCT LIMIT, 297.88,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6365,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6366,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 435.01,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6367,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 435.01,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6368,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6369,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6370,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1180.60,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6371,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1180.60,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6372,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 627.27,,OUTPCT LIMIT, 383.08,OTHER, 225.62, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6373,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1180.60,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6374,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6375,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6376,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6377,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6378,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 627.27,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6379,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 627.27,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6380,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 627.27,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6381,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 627.27,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6382,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6383,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6384,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6385,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6386,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1145.88,,OUTPCT LIMIT, 655.39,OTHER, 225.62, 1207.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6387,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6388,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2409.63,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6389,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1301.52,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6390,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 405.48,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6391,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 85.56,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6392,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 979.64,,OUTPCT LIMIT, 547.41,OTHER, 138.71, 1032.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6393,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 224.68,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6394,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 224.68,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6395,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 272.05,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6396,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 272.05,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6397,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 569.50,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6398,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 746.79,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6399,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 820.26,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6400,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 569.50,,OUTPCT LIMIT, 332.46,OTHER, 140.42, 600.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6401,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 346.67,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6402,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 346.67,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6403,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 224.68,,OUTPCT LIMIT, 174.98,OTHER, 103.88, 239.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6404,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 224.68,,OUTPCT LIMIT, 136.10,OTHER, 76.16, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6405,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 160.89,,OUTPCT LIMIT, 140.33,OTHER, 74.39, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6406,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 395.25,,OUTPCT LIMIT, 228.33,OTHER, 87.35, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6407,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 49.61,,OUTPCT LIMIT, 34.19,OTHER, 22.94, 52.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6408,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 96.72,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6409,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 304.71,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6410,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 304.71,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6411,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 133.39,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6412,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 133.39,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6413,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 684.66,,OUTPCT LIMIT, 415.63,OTHER, 235.80, 721.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6414,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3022.50,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6415,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3022.50,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6416,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3627.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6417,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3627.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6418,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3627.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6419,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 252.23,,OUTPCT LIMIT, 152.82,OTHER, 85.61, 265.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6420,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 275.54,,OUTPCT LIMIT, 165.98,OTHER, 89.47, 290.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6421,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 446.65,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6422,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 446.65,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6423,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 167.59,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6424,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 167.59,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6425,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 531.64,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6426,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 531.64,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6427,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 531.64,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6428,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 153.17,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6429,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 153.24,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6430,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 182.68,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6431,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 182.68,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6432,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 133.86,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6433,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 133.86,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6434,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 143.12,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6435,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 143.12,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6436,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 55.34,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6437,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 55.34,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6438,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 279.78,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6439,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 279.78,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6440,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 158.96,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6441,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 158.96,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6442,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 160.43,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6443,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 160.43,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6444,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 81.80,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6445,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 81.80,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6446,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 89.78,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6447,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 89.78,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6448,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 98.38,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6449,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 98.38,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6450,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 98.38,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6451,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 390.60,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6452,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 125.41,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6453,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 125.41,,OUTPCT LIMIT, 72.71,OTHER, 28.82, 132.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6454,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 114.28,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6455,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 114.20,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6456,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 114.28,,OUTPCT LIMIT, 74.35,OTHER, 52.84, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6457,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 121.89,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6458,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 121.89,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6459,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 121.89,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6460,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 88.47,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6461,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 88.47,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6462,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.89,,OUTPCT LIMIT, 47.68,OTHER, 29.08, 66.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6463,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 166.47,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6464,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 166.47,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6465,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 166.47,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6466,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 199.95,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6467,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 199.95,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6468,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 199.95,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6469,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 114.08,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6470,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 114.08,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6471,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 114.08,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6472,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 40.92,,OUTPCT LIMIT, 30.33,OTHER, 18.92, 43.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6473,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 246.49,,OUTPCT LIMIT, 178.52,OTHER, 113.97, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6474,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 292.49,,OUTPCT LIMIT, 202.67,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6475,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 276.93,,OUTPCT LIMIT, 194.50,OTHER, 128.04, 291.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6476,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 137.97,,OUTPCT LIMIT, 106.37,OTHER, 63.79, 145.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6477,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 236.53,,OUTPCT LIMIT, 173.75,OTHER, 109.36, 249.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6478,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 250.02,,OUTPCT LIMIT, 180.83,OTHER, 115.60, 263.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6479,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 295.08,,OUTPCT LIMIT, 204.49,OTHER, 136.43, 310.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6480,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 142.51,,OUTPCT LIMIT, 108.91,OTHER, 65.89, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6481,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 112.26,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6482,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 112.26,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6483,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 112.26,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6484,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 68.26,,OUTPCT LIMIT, 44.69,OTHER, 31.56, 71.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6485,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 118.71,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6486,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 118.71,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6487,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 82.42,,OUTPCT LIMIT, 59.17,OTHER, 38.11, 86.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6488,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 107.88,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6489,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 107.88,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6490,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 107.88,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6491,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 26.97,,OUTPCT LIMIT, 68.90,OTHER, 12.81, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6492,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 133.70,,OUTPCT LIMIT, 93.12,OTHER, 61.82, 140.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6493,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 112.53,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6494,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 246.49,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6495,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 115.32,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6496,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 115.32,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6497,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 115.32,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6498,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 69.75,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6499,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 96.72,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6500,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 131.13,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6501,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 96.72,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6502,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 131.13,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6503,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 69.75,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6504,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 69.75,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6505,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 279.00,,OUTPCT LIMIT, 192.27,OTHER, 129.00, 294.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6506,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6507,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6508,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 224.68,,OUTPCT LIMIT, 145.27,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6509,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 138.34,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6510,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 138.34,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6511,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 234.43,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6512,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 234.43,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6513,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 366.79,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6514,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 366.79,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6515,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 456.91,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6516,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 456.91,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6517,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 44.27,,OUTPCT LIMIT, 30.51,OTHER, 20.47, 46.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6518,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 96.44,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6519,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 96.44,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6520,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 161.26,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6521,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 161.26,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6522,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 237.94,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6523,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 237.94,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6524,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 318.57,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6525,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 318.57,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6526,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 316.20,,OUTPCT LIMIT, 272.06,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6527,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 391.53,,OUTPCT LIMIT, 336.87,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6528,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 134.85,,OUTPCT LIMIT, 111.61,OTHER, 64.03, 142.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6529,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 164.61,,OUTPCT LIMIT, 149.82,OTHER, 78.16, 173.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6530,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 238.08,,OUTPCT LIMIT, 220.11,OTHER, 113.05, 250.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6531,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 250.10,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6532,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 250.10,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6533,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 233.43,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6534,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 233.43,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6535,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 386.88,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6536,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 386.88,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6537,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 275.28,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6538,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 275.28,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6539,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 611.33,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6540,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 611.33,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6541,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 316.20,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6542,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 316.20,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6543,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 958.90,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6544,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 958.90,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6545,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 391.53,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6546,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 391.53,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6547,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1599.40,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6548,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1599.40,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6549,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 465.93,,OUTPCT LIMIT, 429.06,OTHER, 221.24, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6550,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2558.23,,OUTPCT LIMIT, 1514.86,OTHER, 720.78, 2695.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6551,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 937.82,,OUTPCT LIMIT, 646.30,OTHER, 433.62, 988.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6552,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 27.90,,OUTPCT LIMIT, 19.23,OTHER, 12.90, 29.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6553,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 155.73,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6554,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 155.73,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6555,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 245.06,,OUTPCT LIMIT, 167.97,OTHER, 113.31, 258.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6556,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.33,,OUTPCT LIMIT, 173.37,OTHER, 118.06, 269.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6557,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 266.40,,OUTPCT LIMIT, 179.18,OTHER, 123.17, 280.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6558,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 301.18,,OUTPCT LIMIT, 197.44,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6559,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 292.49,,OUTPCT LIMIT, 192.88,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6560,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 337.54,,OUTPCT LIMIT, 232.62,OTHER, 156.07, 355.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6561,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 366.79,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6562,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 220.55,,OUTPCT LIMIT, 155.10,OTHER, 101.97, 232.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6563,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 235.57,,OUTPCT LIMIT, 162.99,OTHER, 108.92, 248.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6564,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 256.91,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6565,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 256.91,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6566,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 256.91,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6567,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 262.45,,OUTPCT LIMIT, 177.10,OTHER, 121.35, 276.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6568,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 279.84,,OUTPCT LIMIT, 192.85,OTHER, 129.39, 294.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6569,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 301.18,,OUTPCT LIMIT, 207.56,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6570,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 80.63,,OUTPCT LIMIT, 55.57,OTHER, 37.28, 84.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6571,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 138.34,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6572,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 65.10,,OUTPCT LIMIT, 44.86,OTHER, 30.10, 68.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6573,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 247.43,,OUTPCT LIMIT, 170.52,OTHER, 114.40, 260.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6574,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 49.18,,OUTPCT LIMIT, 33.14,OTHER, 22.74, 51.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6575,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 60.87,,OUTPCT LIMIT, 39.28,OTHER, 28.14, 64.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6576,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 87.77,,OUTPCT LIMIT, 60.49,OTHER, 40.58, 92.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6577,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 20.46,,OUTPCT LIMIT, 14.10,OTHER, 9.46, 21.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6578,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 20.46,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6579,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 138.34,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6580,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 237.15,,OUTPCT LIMIT, 148.65,OTHER, 101.33, 249.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6581,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.75,,OUTPCT LIMIT, 166.04,OTHER, 118.25, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6582,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 11.86,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6583,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 11.86,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6584,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 358.05,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6585,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 358.05,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6586,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 564.51,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6587,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 564.51,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6588,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 330.15,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6589,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 330.15,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6590,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 476.16,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6591,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 476.16,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6592,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 816.54,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6593,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 816.54,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6594,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 906.75,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6595,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 906.75,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6596,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 126.48,,OUTPCT LIMIT, 87.16,OTHER, 58.48, 133.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6597,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 59.52,,OUTPCT LIMIT, 41.02,OTHER, 27.52, 62.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6598,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 69.75,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6599,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2786.28,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6600,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2786.28,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6601,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3032.73,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6602,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3032.73,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6603,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2139.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6604,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2139.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6605,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2139.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6606,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1860.00,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6607,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1860.00,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6608,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1860.00,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6609,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1860.00,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6610,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 17.80,,OUTPCT LIMIT, 9.74,OTHER, 1.66, 18.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6611,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 104.77,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6612,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 5.58,,OUTPCT LIMIT, 11.82,OTHER, 2.58, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6613,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 83.79,,OUTPCT LIMIT, 57.75,OTHER, 38.74, 88.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6614,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 43.48,,OUTPCT LIMIT, 29.96,OTHER, 20.10, 45.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6615,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 153.74,,OUTPCT LIMIT, 88.75,OTHER, 33.71, 162.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6616,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 96.72,,OUTPCT LIMIT, 58.81,OTHER, 33.71, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6617,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 363.63,,OUTPCT LIMIT, 250.60,OTHER, 168.13, 383.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6618,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 366.79,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6619,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 366.79,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6620,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 39.53,,OUTPCT LIMIT, 35.44,OTHER, 18.28, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6621,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 56.92,,OUTPCT LIMIT, 44.57,OTHER, 26.32, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6622,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 63.24,,OUTPCT LIMIT, 43.58,OTHER, 29.24, 66.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6623,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6624,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 241.61,,OUTPCT LIMIT, 166.51,OTHER, 111.71, 254.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6625,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 87.21,,OUTPCT LIMIT, 60.10,OTHER, 40.32, 91.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6626,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 7.14,,OUTPCT LIMIT, 4.92,OTHER, 3.30, 7.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6627,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 6.92,,OUTPCT LIMIT, 4.77,OTHER, 3.20, 7.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6628,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 18.90,,OUTPCT LIMIT, 13.02,OTHER, 8.74, 19.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6629,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 195.30,,OUTPCT LIMIT, 134.59,OTHER, 90.30, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6630,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1.97,,OUTPCT LIMIT, 1.36,OTHER, .91, 2.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6631,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3.05,,OUTPCT LIMIT, 2.10,OTHER, 1.41, 3.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6632,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 37.60,,OUTPCT LIMIT, 25.91,OTHER, 17.38, 39.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6633,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 134.95,,OUTPCT LIMIT, 93.00,OTHER, 62.40, 142.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6634,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2.12,,OUTPCT LIMIT, 1.46,OTHER, .98, 2.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6635,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1.49,,OUTPCT LIMIT, 1.03,OTHER, .69, 1.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6636,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 7.48,,OUTPCT LIMIT, 5.15,OTHER, 3.46, 7.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6637,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 16.63,,OUTPCT LIMIT, 11.46,OTHER, 7.69, 17.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6638,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 6.36,,OUTPCT LIMIT, 4.38,OTHER, 2.94, 6.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6639,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 3.72,,OUTPCT LIMIT, 2.56,OTHER, 1.72, 3.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6640,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 10.86,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6641,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 12.09,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6642,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 63.54,,OUTPCT LIMIT, 43.79,OTHER, 29.38, 66.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6643,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 33.41,,OUTPCT LIMIT, 23.02,OTHER, 15.45, 35.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6644,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 9.78,,OUTPCT LIMIT, 6.74,OTHER, 4.52, 10.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6645,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 7.55,,OUTPCT LIMIT, 5.20,OTHER, 3.49, 7.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6646,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 371.07,,OUTPCT LIMIT, 575.18,OTHER, 171.57, 1597.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6647,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 371.07,,OUTPCT LIMIT, 690.66,OTHER, 171.57, 2082.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6648,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 371.07,,OUTPCT LIMIT, 656.15,OTHER, 171.57, 1937.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6649,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 371.07,,OUTPCT LIMIT, 607.70,OTHER, 171.57, 1734.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6650,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 464.07,,OUTPCT LIMIT, 735.35,OTHER, 214.57, 2065.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6651,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 795.15,,OUTPCT LIMIT, 421.89,OTHER, 18.42, 837.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6652,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4.46,,OUTPCT LIMIT, 3.08,OTHER, 2.06, 4.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6653,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 323.64,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6654,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 323.64,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6655,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 323.64,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6656,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 323.64,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6657,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 323.64,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6658,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 323.64,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6659,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 323.64,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6660,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 323.64,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6661,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 323.64,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6662,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 323.64,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6663,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 323.64,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6664,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 323.64,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6665,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 385.95,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6666,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 385.95,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6667,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 385.95,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6668,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 385.95,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6669,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6670,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6671,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6672,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6673,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6674,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6675,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6676,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6677,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6678,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6679,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6680,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6681,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6682,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6683,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6684,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6685,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6686,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6687,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6688,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1233.18,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6689,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 98.81,,OUTPCT LIMIT, 62.01,OTHER, 42.53, 104.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6690,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 106.02,,OUTPCT LIMIT, 73.06,OTHER, 49.02, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6691,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 93.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6692,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 465.00,,OUTPCT LIMIT, 320.46,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6693,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 39.06,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6694,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2.79,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6695,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 32.55,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6696,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2.79,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6697,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 25.11,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6698,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2.79,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6699,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 13.95,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6700,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2.93,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6701,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 69.75,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6702,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2.93,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6703,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4.20,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6704,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 93.93,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6705,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 5.58,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6706,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 5.58,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6707,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 171.05,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6708,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 5.58,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6709,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 167.40,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6710,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 53.94,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6711,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 53.94,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6712,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 308.91,,OUTPCT LIMIT, 212.89,OTHER, 142.83, 325.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6713,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 113.26,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6714,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 69.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6715,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 915.71,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6716,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 666.85,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6717,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 8.37,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6718,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 5.58,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6719,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 93.93,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6720,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 93.93,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6721,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 93.93,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6722,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 93.93,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6723,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 93.93,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6724,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 93.93,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6725,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 93.93,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6726,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 5.58,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6727,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 93.93,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6728,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 94.86,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6729,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 66.81,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6730,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 66.81,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6731,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 69.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6732,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 127.95,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6733,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2.79,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6734,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 13.95,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6735,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 13.95,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6736,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 13.95,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6737,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 16.74,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6738,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 22.32,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6739,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2.79,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6740,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 26.52,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6741,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 26.52,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6742,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 27.90,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6743,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 27.90,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6744,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 27.90,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6745,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 27.90,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6746,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2.79,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6747,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2.78,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6748,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 43.24,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6749,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 9.30,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6750,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2.93,,OUTPCT LIMIT, 2.02,OTHER, 1.35, 3.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6751,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 465.93,,OUTPCT LIMIT, 321.10,OTHER, 215.43, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6752,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 531.96,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6753,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6754,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6755,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6756,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6757,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6758,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6759,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6760,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 31.65,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6761,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 141.54,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6762,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 132.66,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6763,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 86.67,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6764,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 79.55,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6765,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 242.07,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6766,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 7073.30,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6767,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 42.05,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6768,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1655.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6769,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1655.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6770,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1655.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6771,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1655.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6772,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1655.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6773,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1655.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6774,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 2232.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6775,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1655.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6776,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1655.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6777,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1655.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6778,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1655.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6779,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1655.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6780,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1655.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6781,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1302.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6782,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1302.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6783,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 1302.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6784,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6785,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6786,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6787,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 97.65,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6788,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6789,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 62.43,,OUTPCT LIMIT, 43.03,OTHER, 28.87, 65.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6790,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 9.30,,OUTPCT LIMIT, 6.41,OTHER, 4.30, 9.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6791,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 5394.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6792,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4464.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6793,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4464.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6794,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 4464.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6795,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6796,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6797,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 405.48,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6798,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 273.62,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6799,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 282.08,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6800,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 229.81,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6801,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 255.33,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6802,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 527.31,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6803,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 161.26,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6804,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 93.93,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6805,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 94.54,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6806,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 138.34,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6807,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 15.81,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6808,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 26.04,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6809,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6810,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6811,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6812,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6813,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6814,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6815,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6816,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6817,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6818,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6819,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6820,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6821,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, 302.25,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6822,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,FIRST_HEALTH,FIRST HEALTH NETWORK, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6823,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 805.00,,OUTPCT LIMIT, 920.20,OTHER, 507.84, 1127.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6824,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 595.00,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6825,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 962.50,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6826,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6827,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6828,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6829,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6830,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6831,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6832,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6833,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6834,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6835,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6836,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6837,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6838,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6839,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6840,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6841,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 340.76,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6842,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 340.76,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6843,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 193.38,,OUTPCT LIMIT, 168.89,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6844,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 163.80,,OUTPCT LIMIT, 171.36,OTHER, 103.33, 229.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6845,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 343.86,,OUTPCT LIMIT, 273.87,OTHER, 142.76, 481.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6846,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 307.30,,OUTPCT LIMIT, 276.81,OTHER, 142.76, 430.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6847,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 253.47,,OUTPCT LIMIT, 242.16,OTHER, 155.70, 354.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6848,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 322.70,,OUTPCT LIMIT, 850.02,OTHER, 203.58, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6849,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 307.30,,OUTPCT LIMIT, 667.92,OTHER, 193.86, 1237.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6850,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 107.80,,OUTPCT LIMIT, 177.23,OTHER, 68.01, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6851,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 49.00,,OUTPCT LIMIT, 131.69,OTHER, 30.91, 267.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6852,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 88.90,,OUTPCT LIMIT, 116.49,OTHER, 56.08, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6853,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 427.00,,OUTPCT LIMIT, 405.48,OTHER, 256.74, 597.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6854,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 256.90,,OUTPCT LIMIT, 293.67,OTHER, 162.07, 359.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6855,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 170.10,,OUTPCT LIMIT, 216.69,OTHER, 107.31, 256.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6856,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 53.90,,OUTPCT LIMIT, 61.61,OTHER, 34.00, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6857,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 95.90,,OUTPCT LIMIT, 233.68,OTHER, 60.50, 456.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6858,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 146.30,,OUTPCT LIMIT, 158.67,OTHER, 92.29, 204.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6859,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 111.30,,OUTPCT LIMIT, 112.58,OTHER, 70.21, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6860,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 128.80,,OUTPCT LIMIT, 125.44,OTHER, 81.25, 180.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6861,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 81.90,,OUTPCT LIMIT, 114.17,OTHER, 51.67, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6862,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 96.60,,OUTPCT LIMIT, 122.15,OTHER, 60.94, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6863,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 147.00,,OUTPCT LIMIT, 138.81,OTHER, 86.20, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6864,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 117.60,,OUTPCT LIMIT, 117.21,OTHER, 74.19, 164.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6865,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 143.50,,OUTPCT LIMIT, 258.26,OTHER, 90.53, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6866,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 183.40,,OUTPCT LIMIT, 287.58,OTHER, 115.70, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6867,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 247.10,,OUTPCT LIMIT, 334.39,OTHER, 155.88, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6868,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1670.20,,OUTPCT LIMIT, 1514.68,OTHER, 804.50, 2338.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6869,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 943.60,,OUTPCT LIMIT, 1306.30,OTHER, 595.28, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6870,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 425.60,,OUTPCT LIMIT, 925.64,OTHER, 268.49, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6871,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 139.30,,OUTPCT LIMIT, 389.69,OTHER, 87.88, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6872,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 190.40,,OUTPCT LIMIT, 427.24,OTHER, 120.12, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6873,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 231.70,,OUTPCT LIMIT, 457.59,OTHER, 146.17, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6874,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 163.10,,OUTPCT LIMIT, 732.74,OTHER, 102.89, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6875,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 475.30,,OUTPCT LIMIT, 1168.49,OTHER, 299.85, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6876,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 200.90,,OUTPCT LIMIT, 300.44,OTHER, 126.74, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6877,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 282.80,,OUTPCT LIMIT, 495.14,OTHER, 178.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6878,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 336.70,,OUTPCT LIMIT, 534.75,OTHER, 212.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6879,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 388.50,,OUTPCT LIMIT, 572.81,OTHER, 245.09, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6880,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 346.50,,OUTPCT LIMIT, 541.95,OTHER, 218.59, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6881,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 396.90,,OUTPCT LIMIT, 578.99,OTHER, 250.39, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6882,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1215.20,,OUTPCT LIMIT, 1505.88,OTHER, 766.62, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6883,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 489.30,,OUTPCT LIMIT, 646.89,OTHER, 308.68, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6884,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 576.10,,OUTPCT LIMIT, 1242.56,OTHER, 363.44, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6885,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 307.30,,OUTPCT LIMIT, 513.14,OTHER, 193.86, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6886,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 317.80,,OUTPCT LIMIT, 520.86,OTHER, 200.49, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6887,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 554.40,,OUTPCT LIMIT, 694.73,OTHER, 349.75, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6888,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 455.70,,OUTPCT LIMIT, 947.76,OTHER, 287.48, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6889,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 781.20,,OUTPCT LIMIT, 1393.28,OTHER, 492.83, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6890,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 39.20,,OUTPCT LIMIT, 56.01,OTHER, 24.73, 76.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6891,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 236.53,,OUTPCT LIMIT, 185.53,OTHER, 86.20, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6892,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 90.50,,OUTPCT LIMIT, 97.29,OTHER, 57.09, 126.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6893,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 90.30,,OUTPCT LIMIT, 97.14,OTHER, 56.97, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6894,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 35.70,,OUTPCT LIMIT, 57.02,OTHER, 22.52, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6895,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 299.60,,OUTPCT LIMIT, 372.97,OTHER, 189.00, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6896,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 854.00,,OUTPCT LIMIT, 1446.78,OTHER, 538.75, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6897,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 411.60,,OUTPCT LIMIT, 1121.68,OTHER, 259.66, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6898,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 268.62,,OUTPCT LIMIT, 278.63,OTHER, 165.01, 383.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6899,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 482.19,,OUTPCT LIMIT, 427.61,OTHER, 296.20, 675.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6900,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 291.80,,OUTPCT LIMIT, 237.66,OTHER, 143.26, 408.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6901,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 314.72,,OUTPCT LIMIT, 253.66,OTHER, 143.26, 440.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6902,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 341.25,,OUTPCT LIMIT, 272.17,OTHER, 143.26, 477.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6903,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 311.48,,OUTPCT LIMIT, 251.39,OTHER, 143.26, 436.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6904,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 286.30,,OUTPCT LIMIT, 261.55,OTHER, 143.26, 400.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6905,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 330.34,,OUTPCT LIMIT, 264.56,OTHER, 143.26, 462.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6906,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 333.69,,OUTPCT LIMIT, 306.35,OTHER, 204.98, 467.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6907,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 595.70,,OUTPCT LIMIT, 548.12,OTHER, 309.01, 833.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6908,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 344.40,,OUTPCT LIMIT, 300.52,OTHER, 132.82, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6909,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 374.80,,OUTPCT LIMIT, 293.08,OTHER, 132.82, 524.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6910,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1362.10,,OUTPCT LIMIT, 1023.77,OTHER, 309.01, 1906.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6911,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 527.80,,OUTPCT LIMIT, 498.22,OTHER, 309.01, 738.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6912,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2293.38,,OUTPCT LIMIT, 1703.49,OTHER, 435.32, 3210.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6913,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 606.90,,OUTPCT LIMIT, 601.46,OTHER, 382.87, 849.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6914,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1892.10,,OUTPCT LIMIT, 2228.68,OTHER, 1193.64, 2648.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6915,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2055.20,,OUTPCT LIMIT, 2329.49,OTHER, 1296.54, 2877.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6916,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 89.60,,OUTPCT LIMIT, 163.86,OTHER, 56.52, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6917,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 236.53,,OUTPCT LIMIT, 200.99,OTHER, 145.30, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6918,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 84.70,,OUTPCT LIMIT, 93.03,OTHER, 53.43, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6919,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 9.10,,OUTPCT LIMIT, 22.22,OTHER, 5.74, 43.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6920,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 232.40,,OUTPCT LIMIT, 224.77,OTHER, 146.61, 325.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6921,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 123.20,,OUTPCT LIMIT, 251.63,OTHER, 77.72, 451.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6922,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 382.90,,OUTPCT LIMIT, 1148.36,OTHER, 241.56, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6923,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 907.90,,OUTPCT LIMIT, 1534.16,OTHER, 572.76, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6924,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 193.90,,OUTPCT LIMIT, 232.01,OTHER, 122.32, 271.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6925,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 92.82,,OUTPCT LIMIT, 124.43,OTHER, 57.02, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6926,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 86.80,,OUTPCT LIMIT, 120.23,OTHER, 53.32, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6927,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 101.15,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6928,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 101.15,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6929,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 5968.20,,OUTPCT LIMIT, 5204.99,OTHER, 2293.79, 8355.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6930,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 435.40,,OUTPCT LIMIT, 932.84,OTHER, 274.68, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6931,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 553.14,,OUTPCT LIMIT, 424.57,OTHER, 162.56, 774.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6932,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 424.59,,OUTPCT LIMIT, 334.89,OTHER, 162.56, 594.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6933,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 808.38,,OUTPCT LIMIT, 675.88,OTHER, 470.23, 1131.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6934,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 660.94,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6935,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 660.94,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6936,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 242.24,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6937,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 242.24,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6938,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 218.03,,OUTPCT LIMIT, 176.70,OTHER, 103.34, 305.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6939,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 790.97,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6940,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 790.97,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6941,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1376.16,,OUTPCT LIMIT, 1089.64,OTHER, 544.52, 1926.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6942,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 24.50,,OUTPCT LIMIT, 22.43,OTHER, 15.05, 34.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6943,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 21.74,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6944,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 21.74,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6945,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 21.74,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6946,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 21.74,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6947,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 21.74,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6948,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 21.74,,OUTPCT LIMIT, 20.38,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6949,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 17.50,,OUTPCT LIMIT, 16.02,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6950,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 716.88,,OUTPCT LIMIT, 579.04,OTHER, 331.58, 1003.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6951,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1544.20,,OUTPCT LIMIT, 1525.88,OTHER, 974.17, 2161.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6952,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 4368.00,,OUTPCT LIMIT, 4097.24,OTHER, 2484.68, 6115.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6953,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 4645.90,,OUTPCT LIMIT, 4480.28,OTHER, 2930.90, 6504.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6954,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 574.70,,OUTPCT LIMIT, 813.44,OTHER, 362.55, 1095.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6955,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 5034.40,,OUTPCT LIMIT, 4090.68,OTHER, 1095.12, 7048.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6956,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 169.11,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6957,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 169.11,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6958,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 442.40,,OUTPCT LIMIT, 1187.28,OTHER, 279.09, 2414.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6959,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 273.70,,OUTPCT LIMIT, 803.17,OTHER, 172.67, 1685.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6960,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1539.30,,OUTPCT LIMIT, 1733.21,OTHER, 971.08, 2155.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6961,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1975.40,,OUTPCT LIMIT, 1757.99,OTHER, 857.80, 2765.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6962,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 233.10,,OUTPCT LIMIT, 477.65,OTHER, 147.05, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6963,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 260.40,,OUTPCT LIMIT, 497.71,OTHER, 164.28, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6964,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1644.30,,OUTPCT LIMIT, 1514.68,OTHER, 857.80, 2302.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6965,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2323.30,,OUTPCT LIMIT, 2013.65,OTHER, 857.80, 3252.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6966,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 331.10,,OUTPCT LIMIT, 549.67,OTHER, 208.88, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6967,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 370.30,,OUTPCT LIMIT, 578.48,OTHER, 233.61, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6968,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1929.20,,OUTPCT LIMIT, 2205.29,OTHER, 1217.05, 2700.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6969,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2362.50,,OUTPCT LIMIT, 2700.60,OTHER, 1490.40, 3307.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6970,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 816.36,,OUTPCT LIMIT, 718.33,OTHER, 501.48, 1142.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6971,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2132.20,,OUTPCT LIMIT, 2437.34,OTHER, 1345.11, 2985.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6972,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1127.70,,OUTPCT LIMIT, 1780.93,OTHER, 711.42, 2666.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6973,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1049.30,,OUTPCT LIMIT, 2411.76,OTHER, 661.96, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6974,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 110.60,,OUTPCT LIMIT, 283.55,OTHER, 69.77, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6975,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 131.60,,OUTPCT LIMIT, 298.98,OTHER, 83.02, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6976,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 216.30,,OUTPCT LIMIT, 482.77,OTHER, 136.45, 906.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6977,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 387.80,,OUTPCT LIMIT, 603.90,OTHER, 244.65, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6978,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 454.30,,OUTPCT LIMIT, 652.77,OTHER, 286.60, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6979,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 592.20,,OUTPCT LIMIT, 754.11,OTHER, 373.59, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6980,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 540.40,,OUTPCT LIMIT, 716.04,OTHER, 340.92, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6981,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 520.80,,OUTPCT LIMIT, 701.64,OTHER, 328.55, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6982,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2662.10,,OUTPCT LIMIT, 2366.55,OTHER, 1148.80, 3726.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6983,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 175.70,,OUTPCT LIMIT, 623.49,OTHER, 110.84, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6984,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 252.70,,OUTPCT LIMIT, 256.43,OTHER, 159.42, 353.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6985,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 194.60,,OUTPCT LIMIT, 637.38,OTHER, 122.76, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6986,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 194.60,,OUTPCT LIMIT, 982.61,OTHER, 122.76, 2350.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6987,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1037.40,,OUTPCT LIMIT, 1507.20,OTHER, 654.45, 2085.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6988,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2620.10,,OUTPCT LIMIT, 3143.54,OTHER, 1652.91, 3668.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6989,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1150.80,,OUTPCT LIMIT, 2486.35,OTHER, 725.99, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6990,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1250.90,,OUTPCT LIMIT, 2559.90,OTHER, 789.14, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6991,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1246.70,,OUTPCT LIMIT, 1425.12,OTHER, 786.49, 1745.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6992,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2006.20,,OUTPCT LIMIT, 1667.02,OTHER, 539.71, 2808.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6993,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 907.20,,OUTPCT LIMIT, 1786.42,OTHER, 572.31, 3135.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6994,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2479.40,,OUTPCT LIMIT, 3662.54,OTHER, 1564.15, 5153.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6995,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 256.20,,OUTPCT LIMIT, 889.66,OTHER, 161.63, 1963.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6996,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 282.07,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6997,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 282.07,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6998,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1906.80,,OUTPCT LIMIT, 2146.09,OTHER, 1202.92, 2669.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 6999,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 199.77,OTHER, 96.75, 377.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7000,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 266.50,OTHER, 96.75, 657.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7001,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2406.60,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7002,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2406.60,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7003,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 786.00,,OUTPCT LIMIT, 719.65,OTHER, 482.83, 1100.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7004,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1405.99,,OUTPCT LIMIT, 1287.31,OTHER, 863.68, 1968.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7005,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 317.73,,OUTPCT LIMIT, 290.91,OTHER, 195.18, 444.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7006,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1185.80,,OUTPCT LIMIT, 2579.17,OTHER, 748.07, 4781.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7007,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 182.78,,OUTPCT LIMIT, 162.43,OTHER, 112.28, 255.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7008,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 158.26,,OUTPCT LIMIT, 145.32,OTHER, 97.21, 221.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7009,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 101.08,,OUTPCT LIMIT, 116.13,OTHER, 62.09, 191.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7010,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 83.30,,OUTPCT LIMIT, 76.24,OTHER, 51.17, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7011,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 149.14,,OUTPCT LIMIT, 124.60,OTHER, 86.34, 208.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7012,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7013,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.20,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7014,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7015,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 95.90,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7016,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7017,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 184.28,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7018,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7019,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.20,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7020,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7021,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 199.34,,OUTPCT LIMIT, 171.96,OTHER, 122.45, 279.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7022,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7023,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 153.65,,OUTPCT LIMIT, 127.74,OTHER, 86.34, 215.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7024,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7025,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 224.60,,OUTPCT LIMIT, 189.58,OTHER, 137.97, 314.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7026,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7027,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 138.13,,OUTPCT LIMIT, 116.92,OTHER, 84.85, 193.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7028,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7029,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 382.22,,OUTPCT LIMIT, 299.54,OTHER, 138.19, 535.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7030,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7031,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 269.70,,OUTPCT LIMIT, 221.04,OTHER, 138.19, 377.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7032,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7033,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 207.20,,OUTPCT LIMIT, 177.44,OTHER, 127.28, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7034,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7035,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 72.61,,OUTPCT LIMIT, 71.21,OTHER, 44.60, 101.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7036,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7037,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 248.00,,OUTPCT LIMIT, 193.56,OTHER, 86.34, 347.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7038,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7039,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 290.92,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7040,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2049.70,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7041,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1523.54,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7042,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7043,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7044,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1567.02,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7045,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1567.02,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7046,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7047,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7048,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2049.70,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7049,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2049.70,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7050,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7051,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7052,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1272.41,,OUTPCT LIMIT, 955.20,OTHER, 283.82, 1781.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7053,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7054,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 843.54,,OUTPCT LIMIT, 691.35,OTHER, 432.18, 1180.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7055,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7056,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1106.00,,OUTPCT LIMIT, 887.08,OTHER, 485.27, 1548.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7057,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7058,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1194.90,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7059,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1195.17,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7060,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7061,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7062,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1366.17,,OUTPCT LIMIT, 1055.93,OTHER, 432.18, 1912.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7063,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1719.89,,OUTPCT LIMIT, 1302.68,OTHER, 432.18, 2407.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7064,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7065,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7066,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 569.80,,OUTPCT LIMIT, 513.03,OTHER, 350.02, 797.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7067,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7068,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1753.19,,OUTPCT LIMIT, 1290.59,OTHER, 283.82, 2454.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7069,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7070,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1823.29,,OUTPCT LIMIT, 1374.81,OTHER, 432.18, 2552.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7071,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7072,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1649.13,,OUTPCT LIMIT, 1265.96,OTHER, 485.27, 2308.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7073,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7074,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1373.58,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7075,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1373.58,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7076,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1373.58,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7077,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7078,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7079,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7080,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1652.63,,OUTPCT LIMIT, 1270.81,OTHER, 495.38, 2313.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7081,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7082,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2144.57,,OUTPCT LIMIT, 1681.52,OTHER, 779.04, 3002.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7083,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7084,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1582.27,,OUTPCT LIMIT, 1224.87,OTHER, 508.57, 2215.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7085,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7086,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1687.70,,OUTPCT LIMIT, 1324.21,OTHER, 616.91, 2362.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7087,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7088,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1931.65,,OUTPCT LIMIT, 1532.99,OTHER, 779.04, 2704.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7089,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7090,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1594.78,,OUTPCT LIMIT, 1233.59,OTHER, 508.57, 2232.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7091,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7092,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1590.40,,OUTPCT LIMIT, 1256.33,OTHER, 616.91, 2226.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7093,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7094,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1828.58,,OUTPCT LIMIT, 1461.09,OTHER, 779.04, 2560.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7095,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7096,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1852.91,,OUTPCT LIMIT, 1413.66,OTHER, 508.57, 2594.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7097,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7098,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2860.84,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7099,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2860.84,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7100,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7101,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7102,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.20,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7103,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.20,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7104,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.20,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7105,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.20,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7106,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7107,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7108,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7109,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7110,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.20,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7111,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7112,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.20,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7113,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.20,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7114,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7115,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7116,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 317.51,,OUTPCT LIMIT, 242.05,OTHER, 86.34, 444.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7117,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 319.61,,OUTPCT LIMIT, 243.52,OTHER, 86.34, 447.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7118,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7119,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7120,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 259.80,,OUTPCT LIMIT, 214.14,OTHER, 138.19, 363.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7121,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 296.91,,OUTPCT LIMIT, 240.03,OTHER, 138.19, 415.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7122,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7123,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7124,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 309.59,,OUTPCT LIMIT, 248.87,OTHER, 138.19, 433.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7125,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7126,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 207.20,,OUTPCT LIMIT, 165.10,OTHER, 86.34, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7127,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7128,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.20,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7129,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7130,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1639.68,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7131,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1639.68,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7132,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1639.68,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7133,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7134,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7135,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1639.68,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7136,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1955.46,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7137,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7138,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2439.40,,OUTPCT LIMIT, 1817.25,OTHER, 485.27, 3415.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7139,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7140,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1639.68,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7141,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1639.68,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7142,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1639.68,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7143,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7144,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7145,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7146,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3486.02,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7147,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2348.98,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7148,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2348.98,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7149,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2348.98,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7150,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2348.98,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7151,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7152,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7153,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7154,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7155,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 886.20,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7156,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1977.50,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7157,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7158,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7159,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 212.80,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7160,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 212.80,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7161,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7162,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7163,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 307.85,,OUTPCT LIMIT, 247.65,OTHER, 138.19, 430.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7164,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7165,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 455.42,,OUTPCT LIMIT, 350.60,OTHER, 138.19, 637.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7166,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7167,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 501.33,,OUTPCT LIMIT, 382.63,OTHER, 138.19, 701.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7168,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7169,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 373.56,,OUTPCT LIMIT, 293.50,OTHER, 138.19, 522.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7170,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7171,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 333.94,,OUTPCT LIMIT, 265.86,OTHER, 138.19, 467.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7172,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7173,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 184.28,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7174,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7175,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 175.00,,OUTPCT LIMIT, 142.64,OTHER, 86.34, 245.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7176,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7177,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.20,,OUTPCT LIMIT, 63.06,OTHER, 36.98, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7178,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 184.28,,OUTPCT LIMIT, 163.44,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7179,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7180,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 324.45,,OUTPCT LIMIT, 259.24,OTHER, 138.19, 454.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7181,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7182,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.09,,OUTPCT LIMIT, 166.91,OTHER, 118.00, 268.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7183,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7184,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 536.39,,OUTPCT LIMIT, 407.08,OTHER, 138.19, 750.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7185,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7186,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1995.15,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7187,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1995.15,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7188,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1995.15,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7189,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7190,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7191,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7192,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 787.50,,OUTPCT LIMIT, 664.89,OTHER, 483.75, 1102.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7193,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7194,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2267.13,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7195,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2267.13,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7196,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7197,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7198,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2240.00,,OUTPCT LIMIT, 1665.51,OTHER, 432.18, 3136.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7199,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7200,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1966.20,,OUTPCT LIMIT, 1439.18,OTHER, 283.82, 2752.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7201,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7202,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2221.48,,OUTPCT LIMIT, 1652.58,OTHER, 432.18, 3110.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7203,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7204,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2100.00,,OUTPCT LIMIT, 1580.48,OTHER, 485.27, 2940.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7205,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7206,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2281.00,,OUTPCT LIMIT, 1712.29,OTHER, 508.57, 3193.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7207,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7208,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2542.60,,OUTPCT LIMIT, 1894.78,OTHER, 508.57, 3559.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7209,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7210,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2231.74,,OUTPCT LIMIT, 1677.93,OTHER, 508.57, 3124.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7211,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7212,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2772.84,,OUTPCT LIMIT, 2119.80,OTHER, 779.04, 3881.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7213,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7214,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3374.54,,OUTPCT LIMIT, 2539.54,OTHER, 779.04, 4724.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7215,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7216,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3160.46,,OUTPCT LIMIT, 2390.20,OTHER, 779.04, 4424.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7217,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7218,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7219,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7220,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7221,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 292.31,,OUTPCT LIMIT, 236.81,OTHER, 138.19, 409.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7222,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7223,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 230.74,,OUTPCT LIMIT, 193.87,OTHER, 138.19, 323.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7224,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7225,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1711.00,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7226,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1711.00,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7227,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7228,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7229,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1653.12,,OUTPCT LIMIT, 1256.10,OTHER, 432.18, 2314.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7230,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7231,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1116.85,,OUTPCT LIMIT, 894.65,OTHER, 485.27, 1563.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7232,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7233,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2337.24,,OUTPCT LIMIT, 1751.53,OTHER, 508.57, 3272.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7234,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7235,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3503.29,,OUTPCT LIMIT, 2629.35,OTHER, 779.04, 4904.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7236,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7237,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1400.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7238,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1400.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7239,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1400.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7240,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7241,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7242,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7243,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 205.89,,OUTPCT LIMIT, 164.19,OTHER, 86.34, 288.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7244,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7245,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 292.14,,OUTPCT LIMIT, 224.35,OTHER, 86.34, 408.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7246,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7247,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 269.72,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7248,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 269.72,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7249,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 279.76,,OUTPCT LIMIT, 215.71,OTHER, 86.34, 391.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7250,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7251,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7252,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7253,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 184.28,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7254,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 184.28,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7255,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 184.28,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7256,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7257,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7258,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7259,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 222.60,,OUTPCT LIMIT, 175.84,OTHER, 86.34, 311.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7260,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 212.88,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7261,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 212.88,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7262,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7263,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7264,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7265,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 289.80,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7266,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 289.80,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7267,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.39,,OUTPCT LIMIT, 240.36,OTHER, 138.19, 416.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7268,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7269,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7270,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7271,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 285.47,,OUTPCT LIMIT, 219.70,OTHER, 86.34, 399.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7272,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 277.95,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7273,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 277.95,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7274,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7275,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7276,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7277,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 266.63,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7278,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 274.16,,OUTPCT LIMIT, 211.81,OTHER, 86.34, 383.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7279,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 266.63,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7280,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7281,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7282,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7283,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 300.30,,OUTPCT LIMIT, 230.04,OTHER, 86.34, 420.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7284,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 290.92,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7285,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7286,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7287,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7288,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 301.42,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7289,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 301.42,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7290,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 310.80,,OUTPCT LIMIT, 237.37,OTHER, 86.34, 435.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7291,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7292,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7293,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7294,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 95.90,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7295,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 133.00,,OUTPCT LIMIT, 125.68,OTHER, 81.70, 186.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7296,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 95.90,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7297,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7298,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7299,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7300,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 276.92,,OUTPCT LIMIT, 213.73,OTHER, 86.34, 387.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7301,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 268.32,,OUTPCT LIMIT, 207.73,OTHER, 86.34, 375.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7302,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 268.32,,OUTPCT LIMIT, 207.74,OTHER, 86.34, 375.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7303,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7304,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7305,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7306,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 311.97,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7307,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 319.50,,OUTPCT LIMIT, 243.44,OTHER, 86.34, 447.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7308,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 311.97,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7309,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7310,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7311,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7312,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 294.70,,OUTPCT LIMIT, 238.48,OTHER, 138.19, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7313,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 285.32,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7314,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 285.32,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7315,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7316,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7317,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7318,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 286.41,,OUTPCT LIMIT, 220.36,OTHER, 86.34, 400.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7319,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 286.50,,OUTPCT LIMIT, 220.42,OTHER, 86.34, 401.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7320,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 294.03,,OUTPCT LIMIT, 225.67,OTHER, 86.34, 411.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7321,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7322,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7323,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7324,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 238.63,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7325,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 220.96,,OUTPCT LIMIT, 174.69,OTHER, 86.34, 309.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7326,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 213.43,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7327,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 213.43,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7328,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 213.43,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7329,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 213.43,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7330,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 213.43,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7331,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 213.43,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7332,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 213.43,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7333,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 213.43,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7334,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 213.43,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7335,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 213.43,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7336,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 213.43,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7337,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7338,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7339,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7340,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7341,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7342,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7343,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7344,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7345,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7346,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7347,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7348,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7349,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7350,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1324.17,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7351,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1424.16,,OUTPCT LIMIT, 1061.06,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7352,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1424.16,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7353,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1424.16,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7354,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1424.16,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7355,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1424.16,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7356,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1424.16,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7357,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 468.30,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7358,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 468.30,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7359,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1424.16,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7360,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1424.16,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7361,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 468.30,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7362,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1424.16,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7363,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1424.16,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7364,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1324.17,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7365,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7366,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7367,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7368,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7369,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7370,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7371,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7372,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7373,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7374,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7375,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7376,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7377,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7378,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7379,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1980.29,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7380,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1980.29,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7381,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7382,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7383,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7384,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 944.30,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7385,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 944.30,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7386,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7387,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7388,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1339.56,,OUTPCT LIMIT, 1055.55,OTHER, 508.57, 1875.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7389,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7390,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2310.18,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7391,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2310.18,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7392,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2310.18,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7393,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7394,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7395,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7396,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2355.27,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7397,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2355.27,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7398,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2355.27,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7399,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2355.27,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7400,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2355.27,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7401,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2355.27,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7402,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2355.27,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7403,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2355.27,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7404,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2355.27,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7405,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2355.27,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7406,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2355.27,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7407,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2355.27,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7408,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2355.27,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7409,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2355.27,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7410,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2355.27,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7411,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2355.27,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7412,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7413,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7414,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7415,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7416,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7417,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7418,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7419,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7420,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7421,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7422,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7423,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7424,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7425,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7426,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7427,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7428,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1813.18,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7429,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1813.18,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7430,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7431,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7432,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7433,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7434,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7435,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7436,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 252.20,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7437,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 252.20,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7438,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 252.20,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7439,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7440,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7441,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7442,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 243.58,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7443,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 243.58,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7444,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 243.58,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7445,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 243.58,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7446,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 243.58,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7447,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7448,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7449,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7450,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7451,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 318.63,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7452,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 253.38,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7453,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7454,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7455,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 260.78,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7456,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 260.78,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7457,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 268.30,,OUTPCT LIMIT, 208.23,OTHER, 88.46, 375.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7458,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7459,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7460,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7461,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 272.61,,OUTPCT LIMIT, 210.73,OTHER, 86.34, 381.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7462,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 264.01,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7463,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 264.01,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7464,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7465,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7466,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7467,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 338.68,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7468,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 346.21,,OUTPCT LIMIT, 274.41,OTHER, 138.19, 484.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7469,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 338.68,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7470,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7471,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7472,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7473,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 529.20,,OUTPCT LIMIT, 402.07,OTHER, 138.19, 740.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7474,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 519.58,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7475,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 519.58,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7476,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7477,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7478,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7479,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 190.39,,OUTPCT LIMIT, 153.37,OTHER, 86.34, 266.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7480,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7481,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 318.98,,OUTPCT LIMIT, 243.07,OTHER, 86.34, 446.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7482,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 311.45,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7483,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 311.45,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7484,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7485,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7486,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7487,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.20,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7488,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.20,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7489,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 120.40,,OUTPCT LIMIT, 116.89,OTHER, 73.96, 168.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7490,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7491,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7492,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7493,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 266.69,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7494,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 266.69,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7495,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 275.80,,OUTPCT LIMIT, 225.30,OTHER, 138.19, 386.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7496,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7497,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7498,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7499,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 301.70,,OUTPCT LIMIT, 243.37,OTHER, 138.19, 422.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7500,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 292.24,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7501,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 292.24,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7502,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7503,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7504,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7505,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 237.97,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7506,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 237.97,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7507,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7508,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7509,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 329.18,,OUTPCT LIMIT, 250.19,OTHER, 86.34, 460.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7510,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 321.52,,OUTPCT LIMIT, 244.84,OTHER, 86.34, 450.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7511,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 321.66,,OUTPCT LIMIT, 244.94,OTHER, 86.34, 450.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7512,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7513,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7514,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7515,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 163.10,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7516,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 163.10,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7517,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 163.10,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7518,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7519,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7520,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7521,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 217.79,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7522,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 217.79,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7523,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 217.79,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7524,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 217.79,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7525,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 217.79,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7526,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 217.79,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7527,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 217.79,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7528,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 217.79,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7529,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 179.26,OTHER, 86.34, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7530,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 217.79,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7531,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 217.79,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7532,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7533,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7534,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7535,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7536,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7537,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7538,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7539,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7540,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7541,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7542,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7543,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1604.37,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7544,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1604.37,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7545,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1604.37,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7546,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1613.50,,OUTPCT LIMIT, 1193.14,OTHER, 283.82, 2258.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7547,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1604.37,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7548,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1604.37,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7549,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1604.37,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7550,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1604.37,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7551,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1604.37,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7552,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1604.37,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7553,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1604.37,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7554,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1604.37,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7555,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1604.37,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7556,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1604.37,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7557,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7558,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7559,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7560,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7561,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7562,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7563,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7564,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7565,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7566,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7567,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7568,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7569,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7570,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7571,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1909.60,,OUTPCT LIMIT, 1435.02,OTHER, 432.18, 2673.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7572,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1900.10,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7573,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1900.10,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7574,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7575,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7576,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7577,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 944.30,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7578,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 944.30,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7579,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 944.30,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7580,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7581,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7582,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7583,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 972.30,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7584,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 972.30,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7585,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7586,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7587,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2071.26,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7588,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2071.26,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7589,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2071.26,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7590,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2071.26,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7591,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2071.26,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7592,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2071.26,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7593,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7594,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7595,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7596,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7597,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7598,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7599,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2534.27,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7600,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2534.27,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7601,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7602,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7603,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2207.61,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7604,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2207.61,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7605,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2207.62,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7606,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2207.62,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7607,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2207.61,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7608,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2207.61,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7609,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2207.61,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7610,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2207.61,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7611,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2207.61,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7612,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2207.61,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7613,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7614,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7615,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7616,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7617,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7618,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7619,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7620,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7621,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7622,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7623,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3222.04,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7624,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3222.04,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7625,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3222.04,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7626,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3222.04,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7627,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3222.04,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7628,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7629,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7630,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7631,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7632,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7633,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1400.00,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7634,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1610.00,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7635,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1610.00,,OUTPCT LIMIT, 1474.10,OTHER, 989.00, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7636,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1281.00,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7637,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1281.00,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7638,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7639,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7640,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7641,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7642,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7643,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 116.20,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7644,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 116.20,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7645,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7646,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7647,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.20,,OUTPCT LIMIT, 83.13,OTHER, 36.98, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7648,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 105.42,OTHER, 37.54, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7649,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 415.04,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7650,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 415.04,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7651,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7652,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7653,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1832.66,,OUTPCT LIMIT, 1346.03,OTHER, 283.82, 2565.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7654,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7655,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2066.13,,OUTPCT LIMIT, 1544.22,OTHER, 432.18, 2892.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7656,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7657,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2333.25,,OUTPCT LIMIT, 1743.20,OTHER, 485.27, 3266.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7658,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7659,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 4186.02,,OUTPCT LIMIT, 3113.75,OTHER, 813.20, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7660,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 248.50,,OUTPCT LIMIT, 473.04,OTHER, 156.77, 813.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7661,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2330.17,,OUTPCT LIMIT, 1743.46,OTHER, 495.38, 3262.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7662,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7663,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3646.45,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7664,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3646.45,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7665,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7666,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7667,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 4186.02,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7668,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 4186.02,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7669,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7670,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7671,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 4690.15,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7672,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 4690.15,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7673,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 4690.15,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7674,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7675,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7676,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7677,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2248.58,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7678,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2248.58,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7679,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7680,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7681,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2367.53,,OUTPCT LIMIT, 1837.06,OTHER, 779.04, 3314.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7682,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7683,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1750.00,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7684,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2833.60,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7685,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7686,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7687,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7688,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 488.60,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7689,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 488.60,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7690,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 488.60,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7691,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7692,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7693,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 768.97,,OUTPCT LIMIT, 704.06,OTHER, 472.37, 1076.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7694,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 68.02,OTHER, 37.54, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7695,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 270.48,,OUTPCT LIMIT, 248.14,OTHER, 166.15, 378.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7696,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 230.64,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7697,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 531.01,,OUTPCT LIMIT, 429.88,OTHER, 249.71, 743.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7698,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 132.91,OTHER, 37.54, 249.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7699,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1974.83,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7700,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1974.83,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7701,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7702,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7703,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 245.00,,OUTPCT LIMIT, 224.32,OTHER, 150.50, 343.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7704,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7705,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 504.34,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7706,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 504.34,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7707,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 504.34,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7708,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7709,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7710,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7711,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 379.81,,OUTPCT LIMIT, 286.59,OTHER, 90.89, 531.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7712,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7713,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 357.93,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7714,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 357.93,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7715,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 357.93,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7716,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 367.50,,OUTPCT LIMIT, 288.12,OTHER, 133.37, 514.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7717,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7718,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7719,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7720,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7721,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 673.44,,OUTPCT LIMIT, 503.49,OTHER, 141.55, 942.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7722,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7723,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 615.02,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7724,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 615.02,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7725,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 615.02,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7726,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 615.02,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7727,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 615.02,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7728,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7729,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7730,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7731,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7732,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7733,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 615.02,,OUTPCT LIMIT, 468.07,OTHER, 163.97, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7734,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 200.02,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7735,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 554.68,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7736,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 554.68,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7737,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 554.68,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7738,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 554.68,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7739,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 545.88,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7740,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7741,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7742,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7743,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7744,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7745,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 545.88,,OUTPCT LIMIT, 414.50,OTHER, 141.55, 764.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7746,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7747,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 262.50,,OUTPCT LIMIT, 214.87,OTHER, 133.37, 367.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7748,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 163.37,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7749,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 537.61,,OUTPCT LIMIT, 408.73,OTHER, 141.55, 752.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7750,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7751,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 679.27,,OUTPCT LIMIT, 507.55,OTHER, 141.55, 950.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7752,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7753,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1080.80,,OUTPCT LIMIT, 775.60,OTHER, 90.89, 1513.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7754,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7755,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 371.00,,OUTPCT LIMIT, 290.56,OTHER, 133.37, 519.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7756,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7757,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 553.43,,OUTPCT LIMIT, 419.77,OTHER, 141.55, 774.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7758,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7759,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 627.70,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7760,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 627.70,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7761,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 627.70,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7762,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7763,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7764,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7765,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 438.03,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7766,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 423.44,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7767,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7768,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7769,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 537.24,,OUTPCT LIMIT, 408.48,OTHER, 141.55, 752.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7770,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7771,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1120.00,,OUTPCT LIMIT, 813.95,OTHER, 137.10, 1568.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7772,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 708.15,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7773,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 708.15,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7774,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7775,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7776,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7777,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 251.27,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7778,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 385.00,,OUTPCT LIMIT, 300.33,OTHER, 133.37, 539.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7779,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 251.27,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7780,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 251.27,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7781,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 251.27,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7782,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 251.27,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7783,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 251.27,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7784,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 251.27,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7785,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 251.27,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7786,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7787,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7788,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7789,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7790,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7791,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7792,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7793,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7794,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7795,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 465.42,,OUTPCT LIMIT, 426.14,OTHER, 285.90, 651.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7796,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7797,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.21,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7798,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.21,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7799,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.21,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7800,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 249.90,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7801,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7802,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 249.90,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7803,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 249.90,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7804,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 203.70,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7805,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 203.70,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7806,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 99.40,,OUTPCT LIMIT, 91.01,OTHER, 61.06, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7807,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 129.50,,OUTPCT LIMIT, 78.82,OTHER, 21.15, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7808,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 203.70,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7809,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 203.70,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7810,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 203.70,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7811,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 203.70,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7812,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7813,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7814,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7815,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7816,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 343.00,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7817,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 286.30,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7818,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 343.00,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7819,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7820,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7821,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 203.70,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7822,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 203.70,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7823,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 203.70,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7824,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 203.70,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7825,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 420.00,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7826,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 290.50,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7827,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 290.50,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7828,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7829,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7830,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7831,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7832,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7833,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7834,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7835,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 119.70,,OUTPCT LIMIT, 116.40,OTHER, 73.53, 167.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7836,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 29.40,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7837,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 514.38,,OUTPCT LIMIT, 414.07,OTHER, 232.03, 720.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7838,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 137.20,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7839,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 245.70,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7840,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 29.40,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7841,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 29.40,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7842,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 207.20,,OUTPCT LIMIT, 154.63,OTHER, 42.36, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7843,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 245.70,,OUTPCT LIMIT, 204.30,OTHER, 138.19, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7844,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 29.40,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7845,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 893.78,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7846,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 893.78,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7847,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7848,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7849,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 694.79,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7850,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 694.79,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7851,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7852,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7853,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 977.14,,OUTPCT LIMIT, 757.92,OTHER, 320.35, 1367.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7854,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 230.15,OTHER, 99.36, 320.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7855,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1179.77,,OUTPCT LIMIT, 899.81,OTHER, 322.62, 1651.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7856,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 230.96,OTHER, 99.36, 322.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7857,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1379.00,,OUTPCT LIMIT, 1092.65,OTHER, 548.80, 1930.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7858,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 311.74,OTHER, 99.36, 548.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7859,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1094.19,,OUTPCT LIMIT, 864.03,OTHER, 423.08, 1531.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7860,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7861,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 350.00,,OUTPCT LIMIT, 344.89,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7862,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7863,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1050.00,,OUTPCT LIMIT, 830.31,OTHER, 410.92, 1470.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7864,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7865,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1442.00,,OUTPCT LIMIT, 1103.77,OTHER, 410.92, 2018.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7866,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7867,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1470.00,,OUTPCT LIMIT, 1111.16,OTHER, 359.95, 2058.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7868,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7869,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 771.75,,OUTPCT LIMIT, 624.07,OTHER, 359.95, 1080.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7870,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7871,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 840.93,,OUTPCT LIMIT, 672.34,OTHER, 360.01, 1177.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7872,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7873,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 679.00,,OUTPCT LIMIT, 559.38,OTHER, 360.01, 950.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7874,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7875,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1637.55,,OUTPCT LIMIT, 1228.06,OTHER, 360.01, 2292.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7876,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7877,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1732.16,,OUTPCT LIMIT, 1294.05,OTHER, 360.01, 2425.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7878,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7879,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 766.50,,OUTPCT LIMIT, 701.80,OTHER, 470.85, 1073.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7880,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 180.04,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7881,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1262.45,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7882,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1262.45,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7883,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7884,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7885,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2866.00,,OUTPCT LIMIT, 2267.81,OTHER, 1127.76, 4012.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7886,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7887,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1016.47,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7888,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1016.47,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7889,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7890,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7891,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 814.63,,OUTPCT LIMIT, 635.79,OTHER, 283.54, 1140.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7892,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 217.00,OTHER, 99.36, 283.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7893,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1308.18,,OUTPCT LIMIT, 984.09,OTHER, 300.36, 1831.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7894,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 223.01,OTHER, 99.36, 300.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7895,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1354.02,,OUTPCT LIMIT, 1050.06,OTHER, 443.12, 1895.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7896,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 274.00,OTHER, 99.36, 443.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7897,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 728.00,,OUTPCT LIMIT, 684.67,OTHER, 447.20, 1019.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7898,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.50,,OUTPCT LIMIT, 380.97,OTHER, 99.36, 742.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7899,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3334.80,,OUTPCT LIMIT, 2685.69,OTHER, 1509.32, 4668.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7900,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 280.00,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7901,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3453.80,,OUTPCT LIMIT, 2768.70,OTHER, 1509.32, 4835.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7902,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 280.00,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7903,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 42.41,,OUTPCT LIMIT, 34.30,OTHER, 19.78, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7904,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 42.41,,OUTPCT LIMIT, 32.49,OTHER, 12.18, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7905,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 435.40,,OUTPCT LIMIT, 398.65,OTHER, 267.46, 609.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7906,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 97.90,,OUTPCT LIMIT, 70.69,OTHER, 10.09, 137.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7907,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 169.93,,OUTPCT LIMIT, 122.16,OTHER, 15.20, 237.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7908,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 133.33,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7909,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 133.33,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7910,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 115.50,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7911,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 115.50,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7912,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 200.00,,OUTPCT LIMIT, 155.85,OTHER, 68.59, 280.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7913,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 109.21,,OUTPCT LIMIT, 78.98,OTHER, 11.76, 152.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7914,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 91.70,,OUTPCT LIMIT, 69.30,OTHER, 22.37, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7915,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 312.90,,OUTPCT LIMIT, 229.30,OTHER, 46.28, 438.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7916,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 123.38,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7917,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 117.32,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7918,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 70.01,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7919,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 70.01,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7920,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 108.27,,OUTPCT LIMIT, 80.17,OTHER, 19.50, 151.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7921,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 67.63,,OUTPCT LIMIT, 54.61,OTHER, 31.20, 94.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7922,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 108.21,,OUTPCT LIMIT, 80.03,OTHER, 19.08, 151.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7923,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 106.98,,OUTPCT LIMIT, 79.17,OTHER, 19.08, 149.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7924,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 88.42,,OUTPCT LIMIT, 63.95,OTHER, 9.52, 123.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7925,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 32.90,,OUTPCT LIMIT, 28.28,OTHER, 20.21, 46.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7926,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 113.46,,OUTPCT LIMIT, 83.69,OTHER, 19.08, 158.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7927,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 69.13,,OUTPCT LIMIT, 53.47,OTHER, 22.03, 96.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7928,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 107.90,,OUTPCT LIMIT, 79.81,OTHER, 19.08, 151.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7929,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 57.25,,OUTPCT LIMIT, 44.64,OTHER, 19.78, 80.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7930,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 202.42,,OUTPCT LIMIT, 145.91,OTHER, 19.78, 283.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7931,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 85.89,,OUTPCT LIMIT, 64.76,OTHER, 20.36, 120.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7932,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 168.08,,OUTPCT LIMIT, 121.34,OTHER, 17.16, 235.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7933,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 114.84,,OUTPCT LIMIT, 84.76,OTHER, 19.50, 160.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7934,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 181.98,,OUTPCT LIMIT, 134.69,OTHER, 32.53, 254.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7935,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 121.16,,OUTPCT LIMIT, 90.91,OTHER, 26.84, 169.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7936,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 133.24,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7937,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 17.50,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7938,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 28.00,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7939,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 28.00,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7940,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 183.32,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7941,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 206.50,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7942,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 118.30,,OUTPCT LIMIT, 108.31,OTHER, 72.67, 165.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7943,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 105.00,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7944,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 53.20,,OUTPCT LIMIT, 48.71,OTHER, 32.68, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7945,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 196.54,,OUTPCT LIMIT, 179.95,OTHER, 120.73, 275.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7946,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 125.20,,OUTPCT LIMIT, 114.63,OTHER, 76.91, 175.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7947,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 28.58,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7948,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 52.50,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7949,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 28.58,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7950,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 28.58,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7951,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 98.70,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7952,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 74.12,,OUTPCT LIMIT, 67.87,OTHER, 45.53, 103.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7953,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 111.30,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7954,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 111.30,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7955,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 111.30,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7956,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 94.50,,OUTPCT LIMIT, 86.52,OTHER, 58.05, 132.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7957,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.20,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7958,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 203.70,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7959,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 48.45,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7960,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 48.45,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7961,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 48.45,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7962,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 28.90,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7963,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 28.90,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7964,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 28.90,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7965,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 9.10,,OUTPCT LIMIT, 7.12,OTHER, 3.24, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7966,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 10.50,,OUTPCT LIMIT, 8.07,OTHER, 3.12, 14.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7967,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 44.31,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7968,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 44.31,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7969,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 104.30,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7970,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 104.30,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7971,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 172.65,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7972,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 172.65,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7973,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 344.40,,OUTPCT LIMIT, 262.66,OTHER, 94.12, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7974,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 569.90,,OUTPCT LIMIT, 428.98,OTHER, 131.99, 797.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7975,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 141.64,,OUTPCT LIMIT, 129.68,OTHER, 87.01, 198.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7976,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 267.40,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7977,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 267.40,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7978,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.97,,OUTPCT LIMIT, 53.15,OTHER, 6.50, 103.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7979,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 51.76,,OUTPCT LIMIT, 38.90,OTHER, 11.76, 72.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7980,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 191.51,,OUTPCT LIMIT, 146.83,OTHER, 55.61, 268.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7981,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 26.43,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7982,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 26.43,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7983,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 37.63,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7984,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 37.63,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7985,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 84.00,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7986,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 84.00,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7987,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 68.16,,OUTPCT LIMIT, 50.88,OTHER, 13.98, 95.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7988,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 95.26,,OUTPCT LIMIT, 71.06,OTHER, 19.36, 133.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7989,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 150.38,,OUTPCT LIMIT, 109.86,OTHER, 20.82, 210.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7990,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 106.67,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7991,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 106.67,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7992,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 83.30,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7993,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 83.30,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7994,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 69.62,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7995,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 69.62,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7996,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 129.50,,OUTPCT LIMIT, 100.38,OTHER, 42.16, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7997,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 158.96,,OUTPCT LIMIT, 121.92,OTHER, 46.34, 222.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7998,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 61.60,,OUTPCT LIMIT, 50.20,OTHER, 30.37, 86.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 7999,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.42,,OUTPCT LIMIT, 116.31,OTHER, 27.31, 220.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8000,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 66.50,,OUTPCT LIMIT, 49.78,OTHER, 14.24, 93.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8001,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 82.99,,OUTPCT LIMIT, 63.44,OTHER, 23.30, 116.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8002,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 49.66,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8003,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 49.66,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8004,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 44.94,,OUTPCT LIMIT, 33.07,OTHER, 7.22, 62.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8005,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 25.55,,OUTPCT LIMIT, 19.33,OTHER, 6.31, 35.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8006,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 45.62,,OUTPCT LIMIT, 33.34,OTHER, 6.38, 63.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8007,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 56.73,OTHER, 22.92, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8008,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 163.41,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8009,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 174.30,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8010,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 163.41,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8011,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 164.09,,OUTPCT LIMIT, 123.66,OTHER, 38.58, 229.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8012,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.32,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8013,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.32,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8014,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.32,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8015,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 92.53,,OUTPCT LIMIT, 69.24,OTHER, 19.70, 129.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8016,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 68.66,,OUTPCT LIMIT, 49.97,OTHER, 8.69, 96.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8017,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 57.40,,OUTPCT LIMIT, 44.47,OTHER, 18.58, 80.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8018,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 87.33,,OUTPCT LIMIT, 65.14,OTHER, 17.74, 122.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8019,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 115.75,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8020,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 115.75,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8021,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 76.30,,OUTPCT LIMIT, 59.01,OTHER, 24.29, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8022,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 170.17,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8023,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 171.79,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8024,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 75.65,,OUTPCT LIMIT, 56.46,OTHER, 15.47, 105.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8025,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 16.80,,OUTPCT LIMIT, 13.69,OTHER, 8.28, 23.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8026,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 99.57,,OUTPCT LIMIT, 73.71,OTHER, 17.87, 139.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8027,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 117.55,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8028,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 117.55,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8029,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 87.05,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8030,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 87.05,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8031,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 260.79,,OUTPCT LIMIT, 190.19,OTHER, 34.69, 365.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8032,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 294.95,,OUTPCT LIMIT, 214.01,OTHER, 34.69, 412.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8033,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 64.88,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8034,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 64.88,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8035,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 53.20,,OUTPCT LIMIT, 41.70,OTHER, 19.28, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8036,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 79.94,,OUTPCT LIMIT, 59.73,OTHER, 16.63, 111.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8037,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 42.82,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8038,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 42.82,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8039,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 42.82,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8040,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 53.52,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8041,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 53.52,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8042,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 129.34,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8043,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 129.34,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8044,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 58.80,,OUTPCT LIMIT, 45.06,OTHER, 16.97, 82.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8045,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 106.07,,OUTPCT LIMIT, 76.21,OTHER, 9.31, 148.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8046,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 96.13,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8047,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 96.13,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8048,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 98.93,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8049,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 98.93,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8050,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 170.24,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8051,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 170.24,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8052,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 125.33,,OUTPCT LIMIT, 93.87,OTHER, 27.06, 175.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8053,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 180.49,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8054,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 180.49,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8055,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 104.30,,OUTPCT LIMIT, 83.83,OTHER, 46.51, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8056,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 93.80,,OUTPCT LIMIT, 73.72,OTHER, 34.82, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8057,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 95.90,,OUTPCT LIMIT, 75.45,OTHER, 35.93, 134.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8058,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 162.93,,OUTPCT LIMIT, 121.64,OTHER, 33.53, 228.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8059,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 96.64,,OUTPCT LIMIT, 69.17,OTHER, 7.34, 135.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8060,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 170.46,,OUTPCT LIMIT, 124.67,OTHER, 24.19, 238.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8061,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 102.90,,OUTPCT LIMIT, 76.46,OTHER, 19.63, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8062,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 95.24,,OUTPCT LIMIT, 71.48,OTHER, 21.17, 133.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8063,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 296.63,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8064,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 108.51,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8065,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 74.03,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8066,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 74.03,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8067,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 74.03,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8068,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 85.03,,OUTPCT LIMIT, 64.96,OTHER, 23.70, 119.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8069,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.20,,OUTPCT LIMIT, 34.98,OTHER, 11.54, 64.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8070,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 278.94,,OUTPCT LIMIT, 203.52,OTHER, 37.54, 390.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8071,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 79.80,,OUTPCT LIMIT, 61.71,OTHER, 25.39, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8072,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 34.83,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8073,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 34.83,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8074,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 34.83,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8075,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 38.66,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8076,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 38.66,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8077,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 38.66,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8078,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 18.34,,OUTPCT LIMIT, 14.14,OTHER, 5.66, 25.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8079,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 90.07,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8080,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 90.07,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8081,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 78.25,,OUTPCT LIMIT, 57.91,OTHER, 13.97, 109.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8082,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 50.28,,OUTPCT LIMIT, 37.55,OTHER, 10.37, 70.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8083,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 126.67,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8084,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 126.67,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8085,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 126.39,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8086,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 126.39,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8087,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 89.93,,OUTPCT LIMIT, 67.05,OTHER, 18.12, 125.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8088,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 96.60,,OUTPCT LIMIT, 74.92,OTHER, 31.62, 135.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8089,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 64.47,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8090,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 64.47,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8091,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 64.47,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8092,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 134.30,,OUTPCT LIMIT, 99.83,OTHER, 25.80, 188.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8093,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 210.70,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8094,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 185.77,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8095,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 185.77,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8096,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 185.77,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8097,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 185.77,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8098,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 185.77,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8099,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 207.63,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8100,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 125.34,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8101,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 193.26,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8102,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 30.10,,OUTPCT LIMIT, 25.93,OTHER, 18.49, 42.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8103,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 93.35,,OUTPCT LIMIT, 69.04,OTHER, 16.46, 130.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8104,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.72,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8105,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.72,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8106,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.72,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8107,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.08,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8108,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.08,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8109,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.08,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8110,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.08,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8111,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 94.71,,OUTPCT LIMIT, 70.04,OTHER, 16.66, 132.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8112,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.52,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8113,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 79.74,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8114,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 116.20,,OUTPCT LIMIT, 85.45,OTHER, 18.42, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8115,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 88.90,,OUTPCT LIMIT, 68.77,OTHER, 28.37, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8116,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 72.56,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8117,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 72.56,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8118,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 83.31,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8119,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 83.31,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8120,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 190.90,,OUTPCT LIMIT, 149.05,OTHER, 66.68, 267.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8121,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 45.50,,OUTPCT LIMIT, 43.46,OTHER, 27.95, 63.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8122,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 56.49,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8123,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 56.49,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8124,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 54.96,,OUTPCT LIMIT, 40.64,OTHER, 9.65, 76.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8125,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 280.64,,OUTPCT LIMIT, 204.04,OTHER, 34.72, 392.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8126,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 74.42,,OUTPCT LIMIT, 57.49,OTHER, 23.41, 104.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8127,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 220.41,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8128,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 220.41,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8129,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 116.67,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8130,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 85.06,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8131,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 153.30,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8132,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 153.30,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8133,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 148.63,,OUTPCT LIMIT, 110.95,OTHER, 30.54, 208.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8134,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 74.40,,OUTPCT LIMIT, 54.17,OTHER, 9.52, 104.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8135,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.37,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8136,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.37,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8137,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 116.39,,OUTPCT LIMIT, 86.15,OTHER, 20.81, 162.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8138,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 190.44,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8139,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 190.44,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8140,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 53.20,,OUTPCT LIMIT, 43.75,OTHER, 27.89, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8141,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 257.86,,OUTPCT LIMIT, 186.61,OTHER, 28.27, 361.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8142,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.20,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8143,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 66.22,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8144,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 48.12,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8145,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 48.12,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8146,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 39.05,,OUTPCT LIMIT, 28.87,OTHER, 6.85, 54.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8147,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 17.50,,OUTPCT LIMIT, 13.83,OTHER, 6.82, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8148,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 58.14,,OUTPCT LIMIT, 45.56,OTHER, 21.01, 81.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8149,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 122.67,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8150,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 122.67,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8151,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 133.98,,OUTPCT LIMIT, 102.79,OTHER, 39.19, 187.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8152,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 129.77,,OUTPCT LIMIT, 97.17,OTHER, 27.91, 181.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8153,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 115.72,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8154,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 124.84,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8155,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 124.84,,OUTPCT LIMIT, 93.39,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8156,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 33.54,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8157,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 33.54,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8158,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 81.11,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8159,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 81.11,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8160,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 81.11,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8161,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 57.26,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8162,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 57.26,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8163,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.79,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8164,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 278.66,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8165,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 123.80,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8166,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 106.76,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8167,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 281.66,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8168,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 182.34,,OUTPCT LIMIT, 136.35,OTHER, 38.44, 255.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8169,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 134.23,,OUTPCT LIMIT, 103.27,OTHER, 40.46, 187.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8170,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 99.40,,OUTPCT LIMIT, 76.88,OTHER, 31.67, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8171,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 246.40,,OUTPCT LIMIT, 178.83,OTHER, 29.15, 344.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8172,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 116.08,,OUTPCT LIMIT, 88.43,OTHER, 31.30, 162.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8173,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 40.67,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8174,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 40.67,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8175,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 63.26,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8176,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 63.26,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8177,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 12.99,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8178,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 248.62,,OUTPCT LIMIT, 180.72,OTHER, 30.61, 348.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8179,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 430.30,,OUTPCT LIMIT, 302.95,OTHER, 11.66, 602.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8180,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 104.88,,OUTPCT LIMIT, 81.90,OTHER, 36.67, 146.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8181,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 163.81,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8182,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 163.81,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8183,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 163.81,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8184,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 163.81,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8185,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 113.99,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8186,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 113.99,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8187,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 146.00,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8188,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 146.00,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8189,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 72.99,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8190,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 72.99,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8191,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 104.44,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8192,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 104.44,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8193,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 104.44,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8194,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 67.20,,OUTPCT LIMIT, 51.95,OTHER, 21.29, 94.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8195,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 97.15,,OUTPCT LIMIT, 73.53,OTHER, 24.19, 136.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8196,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 196.00,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8197,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 196.00,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8198,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 64.40,,OUTPCT LIMIT, 49.79,OTHER, 20.42, 90.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8199,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 52.38,,OUTPCT LIMIT, 38.32,OTHER, 7.46, 73.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8200,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 48.99,,OUTPCT LIMIT, 35.99,OTHER, 7.63, 68.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8201,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 77.60,,OUTPCT LIMIT, 58.51,OTHER, 18.37, 108.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8202,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 53.28,,OUTPCT LIMIT, 39.13,OTHER, 8.27, 74.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8203,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 106.86,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8204,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 106.86,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8205,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 104.78,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8206,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 104.78,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8207,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 174.15,,OUTPCT LIMIT, 126.89,OTHER, 22.69, 243.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8208,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 112.84,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8209,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 112.84,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8210,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 54.15,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8211,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 54.15,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8212,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 54.15,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8213,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 29.67,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8214,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 29.67,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8215,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 43.47,,OUTPCT LIMIT, 31.87,OTHER, 6.50, 60.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8216,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 53.55,,OUTPCT LIMIT, 39.10,OTHER, 7.32, 74.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8217,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 103.72,,OUTPCT LIMIT, 76.33,OTHER, 16.72, 145.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8218,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 141.93,,OUTPCT LIMIT, 103.71,OTHER, 19.75, 198.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8219,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 75.66,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8220,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 75.66,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8221,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 75.66,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8222,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 112.49,,OUTPCT LIMIT, 85.61,OTHER, 29.96, 157.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8223,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 131.71,,OUTPCT LIMIT, 97.04,OTHER, 21.67, 184.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8224,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.10,,OUTPCT LIMIT, 42.88,OTHER, 6.94, 82.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8225,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.92,,OUTPCT LIMIT, 43.80,OTHER, 5.47, 85.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8226,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 24.42,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8227,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 24.42,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8228,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 29.60,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8229,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 29.60,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8230,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8231,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.14,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8232,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.91,,OUTPCT LIMIT, 44.71,OTHER, 9.31, 85.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8233,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 52.02,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8234,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 52.02,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8235,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 27.30,,OUTPCT LIMIT, 19.92,OTHER, 3.66, 38.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8236,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 44.57,,OUTPCT LIMIT, 32.63,OTHER, 6.46, 62.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8237,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 129.93,,OUTPCT LIMIT, 96.77,OTHER, 25.78, 181.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8238,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 174.08,,OUTPCT LIMIT, 129.31,OTHER, 33.04, 243.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8239,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 181.30,,OUTPCT LIMIT, 130.54,OTHER, 17.06, 253.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8240,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 134.17,,OUTPCT LIMIT, 98.34,OTHER, 19.93, 187.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8241,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 120.05,,OUTPCT LIMIT, 89.00,OTHER, 22.06, 168.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8242,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 135.80,,OUTPCT LIMIT, 98.22,OTHER, 14.66, 190.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8243,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.54,,OUTPCT LIMIT, 54.63,OTHER, 13.99, 102.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8244,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 91.70,,OUTPCT LIMIT, 70.40,OTHER, 27.00, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8245,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 40.78,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8246,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 40.52,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8247,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 40.78,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8248,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 18.20,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8249,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 18.20,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8250,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 18.20,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8251,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 18.20,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8252,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 57.54,,OUTPCT LIMIT, 41.60,OTHER, 6.14, 80.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8253,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 36.40,,OUTPCT LIMIT, 26.32,OTHER, 3.89, 50.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8254,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 49.40,,OUTPCT LIMIT, 36.35,OTHER, 7.93, 69.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8255,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 119.00,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8256,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 52.42,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8257,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 106.06,,OUTPCT LIMIT, 76.67,OTHER, 11.26, 148.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8258,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 831.85,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8259,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 226.10,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8260,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8261,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8262,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8263,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8264,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8265,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8266,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8267,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8268,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8269,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8270,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8271,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8272,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8273,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8274,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8275,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8276,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8277,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8278,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8279,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8280,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8281,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8282,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8283,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8284,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8285,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8286,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8287,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8288,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8289,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8290,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8291,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8292,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8293,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8294,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8295,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8296,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 43.15,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8297,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8298,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8299,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8300,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8301,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 22.47,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8302,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8303,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8304,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8305,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8306,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8307,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8308,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8309,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8310,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8311,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8312,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8313,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8314,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8315,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8316,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8317,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8318,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8319,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8320,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 262.33,,OUTPCT LIMIT, 189.29,OTHER, 26.45, 367.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8321,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 160.17,,OUTPCT LIMIT, 115.17,OTHER, 14.46, 224.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8322,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 93.31,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8323,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 157.70,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8324,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 64.63,,OUTPCT LIMIT, 48.91,OTHER, 16.07, 90.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8325,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 61.25,,OUTPCT LIMIT, 45.23,OTHER, 10.51, 85.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8326,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 21.94,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8327,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 21.94,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8328,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 78.58,,OUTPCT LIMIT, 59.25,OTHER, 18.65, 110.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8329,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 122.21,,OUTPCT LIMIT, 93.98,OTHER, 36.65, 171.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8330,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 184.42,,OUTPCT LIMIT, 137.37,OTHER, 36.65, 258.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8331,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 104.58,,OUTPCT LIMIT, 78.46,OTHER, 23.14, 146.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8332,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 91.18,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8333,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 90.95,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8334,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 101.38,,OUTPCT LIMIT, 77.69,OTHER, 29.26, 141.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8335,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 84.21,,OUTPCT LIMIT, 63.19,OTHER, 18.65, 117.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8336,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 84.09,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8337,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 91.29,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8338,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 99.02,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8339,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 99.02,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8340,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 99.02,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8341,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 99.02,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8342,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 99.13,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8343,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 99.02,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8344,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 84.60,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8345,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 78.86,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8346,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 111.30,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8347,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 170.22,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8348,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 164.33,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8349,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 17.50,,OUTPCT LIMIT, 15.65,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8350,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 104.33,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8351,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 107.27,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8352,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 111.80,,OUTPCT LIMIT, 85.12,OTHER, 29.96, 156.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8353,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 138.07,,OUTPCT LIMIT, 103.45,OTHER, 29.96, 193.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8354,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 94.71,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8355,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 246.75,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8356,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 69.90,,OUTPCT LIMIT, 50.54,OTHER, 7.46, 97.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8357,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 116.42,,OUTPCT LIMIT, 88.87,OTHER, 32.17, 162.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8358,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 84.70,,OUTPCT LIMIT, 66.43,OTHER, 30.83, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8359,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 74.91,,OUTPCT LIMIT, 57.43,OTHER, 21.72, 104.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8360,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 368.38,,OUTPCT LIMIT, 265.06,OTHER, 33.95, 515.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8361,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 102.90,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8362,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 102.90,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8363,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 141.75,,OUTPCT LIMIT, 111.82,OTHER, 54.34, 198.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8364,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 229.53,,OUTPCT LIMIT, 176.22,OTHER, 67.64, 321.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8365,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 113.05,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8366,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 113.05,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8367,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 93.80,,OUTPCT LIMIT, 68.73,OTHER, 13.84, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8368,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 114.18,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8369,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 147.00,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8370,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 93.80,,OUTPCT LIMIT, 70.10,OTHER, 19.60, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8371,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 64.39,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8372,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 64.39,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8373,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 244.30,,OUTPCT LIMIT, 191.67,OTHER, 89.24, 342.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8374,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 13.09,,OUTPCT LIMIT, 12.31,OTHER, 8.04, 18.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8375,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 24.44,,OUTPCT LIMIT, 18.56,OTHER, 6.34, 34.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8376,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 44.51,,OUTPCT LIMIT, 36.21,OTHER, 21.67, 62.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8377,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 74.20,,OUTPCT LIMIT, 55.25,OTHER, 14.66, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8378,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 51.18,,OUTPCT LIMIT, 40.13,OTHER, 18.58, 71.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8379,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 88.90,,OUTPCT LIMIT, 66.54,OTHER, 19.00, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8380,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 118.32,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8381,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 118.32,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8382,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 118.32,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8383,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 32.44,,OUTPCT LIMIT, 26.75,OTHER, 17.29, 45.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8384,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 67.85,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8385,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 182.00,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8386,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 65.80,,OUTPCT LIMIT, 50.83,OTHER, 20.72, 92.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8387,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 76.30,,OUTPCT LIMIT, 59.00,OTHER, 24.26, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8388,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 84.88,,OUTPCT LIMIT, 64.46,OTHER, 22.02, 118.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8389,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 76.38,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8390,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 76.38,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8391,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 128.09,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8392,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 77.09,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8393,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 77.09,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8394,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 86.10,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8395,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 86.10,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8396,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 55.30,,OUTPCT LIMIT, 43.51,OTHER, 20.72, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8397,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 61.87,,OUTPCT LIMIT, 47.68,OTHER, 19.00, 86.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8398,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 74.20,,OUTPCT LIMIT, 58.39,OTHER, 27.86, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8399,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 104.27,,OUTPCT LIMIT, 77.47,OTHER, 19.86, 145.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8400,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 82.86,,OUTPCT LIMIT, 62.50,OTHER, 19.74, 116.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8401,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 61.09,,OUTPCT LIMIT, 46.75,OTHER, 17.35, 85.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8402,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 53.20,,OUTPCT LIMIT, 41.14,OTHER, 16.94, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8403,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 90.88,,OUTPCT LIMIT, 67.08,OTHER, 15.47, 127.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8404,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 66.34,,OUTPCT LIMIT, 50.52,OTHER, 17.84, 92.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8405,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 34.86,,OUTPCT LIMIT, 28.18,OTHER, 16.21, 48.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8406,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 68.91,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8407,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 68.91,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8408,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 52.50,,OUTPCT LIMIT, 41.16,OTHER, 19.07, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8409,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.03,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8410,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.03,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8411,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.03,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8412,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 61.08,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8413,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 63.18,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8414,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 63.18,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8415,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 64.28,,OUTPCT LIMIT, 49.38,OTHER, 19.07, 89.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8416,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 108.51,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8417,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 108.51,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8418,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 512.25,,OUTPCT LIMIT, 361.76,OTHER, 18.55, 717.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8419,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 224.70,,OUTPCT LIMIT, 161.64,OTHER, 20.54, 314.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8420,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 195.84,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8421,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 195.84,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8422,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 107.03,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8423,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 107.03,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8424,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 107.03,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8425,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 167.30,,OUTPCT LIMIT, 152.44,OTHER, 102.77, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8426,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 301.60,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8427,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 301.60,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8428,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 301.60,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8429,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 114.56,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8430,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 114.56,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8431,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 114.56,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8432,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 114.56,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8433,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 114.56,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8434,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 207.98,,OUTPCT LIMIT, 146.86,OTHER, 7.46, 291.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8435,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 77.00,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8436,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 77.00,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8437,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 77.00,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8438,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 63.76,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8439,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.59,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8440,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 63.76,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8441,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 301.60,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8442,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 301.60,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8443,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 274.05,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8444,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 97.65,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8445,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 97.65,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8446,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 415.95,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8447,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 415.95,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8448,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 415.95,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8449,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 415.95,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8450,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 415.95,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8451,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 415.95,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8452,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 97.65,,OUTPCT LIMIT, 76.50,OTHER, 35.20, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8453,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 182.70,,OUTPCT LIMIT, 149.18,OTHER, 91.25, 255.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8454,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 111.62,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8455,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 111.62,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8456,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 39.46,,OUTPCT LIMIT, 30.76,OTHER, 13.60, 55.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8457,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 99.89,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8458,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 99.89,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8459,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 107.53,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8460,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 107.53,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8461,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 109.26,,OUTPCT LIMIT, 78.99,OTHER, 11.64, 152.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8462,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 63.08,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8463,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 63.08,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8464,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 63.08,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8465,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 55.46,,OUTPCT LIMIT, 40.96,OTHER, 9.55, 77.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8466,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.08,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8467,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.08,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8468,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.08,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8469,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 113.95,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8470,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 113.95,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8471,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 103.01,,OUTPCT LIMIT, 74.74,OTHER, 12.11, 144.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8472,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 125.15,,OUTPCT LIMIT, 91.00,OTHER, 15.55, 175.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8473,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 93.55,,OUTPCT LIMIT, 68.31,OTHER, 12.82, 130.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8474,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 23.10,,OUTPCT LIMIT, 17.74,OTHER, 6.84, 32.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8475,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 29.28,,OUTPCT LIMIT, 22.99,OTHER, 10.78, 40.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8476,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 40.60,,OUTPCT LIMIT, 29.95,OTHER, 6.84, 56.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8477,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 56.55,,OUTPCT LIMIT, 42.41,OTHER, 12.46, 79.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8478,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 39.61,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8479,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 36.88,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8480,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 36.88,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8481,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 37.02,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8482,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 37.02,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8483,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 52.03,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8484,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 52.03,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8485,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 37.70,,OUTPCT LIMIT, 28.29,OTHER, 8.38, 52.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8486,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 88.90,,OUTPCT LIMIT, 68.72,OTHER, 28.16, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8487,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 423.29,,OUTPCT LIMIT, 299.39,OTHER, 17.26, 592.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8488,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 53.21,,OUTPCT LIMIT, 40.67,OTHER, 14.88, 74.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8489,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 56.08,,OUTPCT LIMIT, 43.08,OTHER, 16.61, 78.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8490,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 167.30,,OUTPCT LIMIT, 121.25,OTHER, 19.08, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8491,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 88.90,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8492,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 135.10,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8493,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 135.11,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8494,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 135.10,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8495,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 135.10,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8496,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 135.10,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8497,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 264.01,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8498,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 264.01,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8499,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 109.99,,OUTPCT LIMIT, 100.71,OTHER, 67.57, 153.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8500,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 296.43,,OUTPCT LIMIT, 221.47,OTHER, 61.69, 415.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8501,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 92.32,,OUTPCT LIMIT, 76.43,OTHER, 50.53, 129.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8502,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 338.10,,OUTPCT LIMIT, 265.03,OTHER, 122.54, 473.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8503,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 135.11,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8504,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 105.00,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8505,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 105.00,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8506,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 434.04,,OUTPCT LIMIT, 445.68,OTHER, 266.63, 607.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8507,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 70.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8508,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 70.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8509,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 70.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8510,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 260.83,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8511,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 260.83,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8512,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8513,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 231.70,,OUTPCT LIMIT, 173.66,OTHER, 50.53, 324.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8514,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 88.90,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8515,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 122.64,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8516,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 428.36,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8517,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 188.98,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8518,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 188.98,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8519,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 81.11,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8520,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 81.11,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8521,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 55.30,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8522,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 55.30,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8523,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 55.30,,OUTPCT LIMIT, 44.25,OTHER, 23.81, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8524,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 17.50,,OUTPCT LIMIT, 17.88,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8525,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 135.65,,OUTPCT LIMIT, 100.14,OTHER, 23.14, 189.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8526,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1021.30,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8527,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1021.30,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8528,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 72.80,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8529,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 72.80,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8530,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 388.50,,OUTPCT LIMIT, 294.34,OTHER, 97.97, 543.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8531,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8532,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8533,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 21.70,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8534,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 21.70,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8535,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 78.69,,OUTPCT LIMIT, 56.81,OTHER, 8.06, 110.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8536,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 53.70,,OUTPCT LIMIT, 39.98,OTHER, 10.56, 75.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8537,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 53.90,,OUTPCT LIMIT, 41.73,OTHER, 17.35, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8538,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 4152.70,,OUTPCT LIMIT, 3802.17,OTHER, 2550.94, 5813.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8539,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 78.86,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8540,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 78.86,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8541,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 20.65,,OUTPCT LIMIT, 23.30,OTHER, 12.69, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8542,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 41.65,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8543,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 20.83,,OUTPCT LIMIT, 23.42,OTHER, 12.79, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8544,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 90.30,,OUTPCT LIMIT, 82.68,OTHER, 55.47, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8545,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8546,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 107.10,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8547,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 107.10,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8548,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 97.27,,OUTPCT LIMIT, 89.06,OTHER, 59.75, 136.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8549,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 35.00,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8550,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 35.00,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8551,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 415.37,,OUTPCT LIMIT, 356.50,OTHER, 255.16, 581.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8552,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 867.85,,OUTPCT LIMIT, 687.64,OTHER, 345.38, 1214.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8553,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 220.15,,OUTPCT LIMIT, 201.57,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8554,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8555,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8556,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.50,,OUTPCT LIMIT, 60.00,OTHER, 36.55, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8557,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 36.02,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8558,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 36.02,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8559,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8560,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8561,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8562,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 7.70,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8563,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 7.70,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8564,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 7.70,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8565,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 7.70,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8566,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 55.82,,OUTPCT LIMIT, 51.11,OTHER, 34.29, 78.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8567,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 95.70,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8568,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 95.70,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8569,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8570,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 110.46,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8571,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 110.46,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8572,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8573,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8574,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 119.64,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8575,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 119.64,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8576,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 7.00,,OUTPCT LIMIT, 12.78,OTHER, 4.30, 33.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8577,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 23.14,,OUTPCT LIMIT, 17.36,OTHER, 5.09, 32.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8578,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 212.74,,OUTPCT LIMIT, 184.48,OTHER, 130.68, 297.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8579,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 238.36,,OUTPCT LIMIT, 202.35,OTHER, 146.42, 333.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8580,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 103.56,,OUTPCT LIMIT, 99.37,OTHER, 63.61, 144.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8581,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 106.45,,OUTPCT LIMIT, 88.44,OTHER, 59.56, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8582,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 137.11,,OUTPCT LIMIT, 131.72,OTHER, 84.22, 191.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8583,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 134.80,,OUTPCT LIMIT, 117.05,OTHER, 82.81, 188.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8584,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 205.95,,OUTPCT LIMIT, 179.75,OTHER, 126.51, 288.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8585,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 178.19,,OUTPCT LIMIT, 158.52,OTHER, 109.46, 249.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8586,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 215.22,,OUTPCT LIMIT, 186.21,OTHER, 132.20, 301.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8587,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 102.98,,OUTPCT LIMIT, 83.96,OTHER, 50.93, 144.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8588,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 166.04,,OUTPCT LIMIT, 167.44,OTHER, 102.00, 232.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8589,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 172.98,,OUTPCT LIMIT, 172.28,OTHER, 106.26, 242.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8590,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 41.66,,OUTPCT LIMIT, 49.86,OTHER, 25.59, 87.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8591,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 173.56,,OUTPCT LIMIT, 141.43,OTHER, 85.51, 242.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8592,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.93,,OUTPCT LIMIT, 69.71,OTHER, 45.42, 103.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8593,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 196.12,,OUTPCT LIMIT, 177.65,OTHER, 120.47, 274.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8594,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 213.04,,OUTPCT LIMIT, 189.46,OTHER, 130.87, 298.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8595,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 342.73,,OUTPCT LIMIT, 279.93,OTHER, 171.54, 479.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8596,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 321.33,,OUTPCT LIMIT, 265.00,OTHER, 171.54, 449.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8597,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 176.11,,OUTPCT LIMIT, 149.90,OTHER, 108.18, 246.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8598,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 223.69,,OUTPCT LIMIT, 167.02,OTHER, 46.09, 313.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8599,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 93.36,,OUTPCT LIMIT, 76.10,OTHER, 46.09, 130.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8600,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 195.49,,OUTPCT LIMIT, 147.35,OTHER, 46.09, 273.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8601,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 283.29,,OUTPCT LIMIT, 227.22,OTHER, 124.32, 396.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8602,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 381.15,,OUTPCT LIMIT, 295.49,OTHER, 124.32, 533.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8603,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 121.56,,OUTPCT LIMIT, 114.40,OTHER, 74.67, 170.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8604,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 180.45,,OUTPCT LIMIT, 155.48,OTHER, 110.85, 252.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8605,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 27.97,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8606,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 27.97,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8607,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 27.97,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8608,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 13.69,,OUTPCT LIMIT, 36.72,OTHER, 8.41, 114.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8609,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 257.85,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8610,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 257.85,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8611,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 636.74,,OUTPCT LIMIT, 526.62,OTHER, 346.21, 891.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8612,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 290.83,OTHER, 143.52, 346.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8613,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 233.29,,OUTPCT LIMIT, 266.67,OTHER, 147.17, 326.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8614,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 215.60,,OUTPCT LIMIT, 162.12,OTHER, 49.24, 301.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8615,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 173.60,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8616,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 173.60,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8617,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 221.90,,OUTPCT LIMIT, 166.97,OTHER, 51.13, 310.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8618,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 61.33,,OUTPCT LIMIT, 54.96,OTHER, 37.67, 85.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8619,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 106.45,,OUTPCT LIMIT, 86.43,OTHER, 51.13, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8620,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1138.68,,OUTPCT LIMIT, 950.56,OTHER, 656.16, 1594.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8621,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 375.80,OTHER, 121.44, 656.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8622,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 651.00,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8623,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 651.00,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8624,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8625,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8626,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 771.59,,OUTPCT LIMIT, 591.97,OTHER, 225.62, 1080.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8627,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8628,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 325.98,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8629,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 325.98,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8630,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 197.77,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8631,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 730.99,,OUTPCT LIMIT, 563.65,OTHER, 225.62, 1023.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8632,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8633,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 114.10,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8634,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 114.10,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8635,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8636,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8637,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 350.00,,OUTPCT LIMIT, 297.88,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8638,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8639,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 327.43,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8640,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 327.43,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8641,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8642,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8643,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 888.62,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8644,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 888.62,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8645,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 472.14,,OUTPCT LIMIT, 383.08,OTHER, 225.62, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8646,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 888.62,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8647,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8648,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8649,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8650,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8651,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 472.14,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8652,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 472.14,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8653,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 472.14,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8654,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 472.14,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8655,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8656,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8657,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8658,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8659,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 862.49,,OUTPCT LIMIT, 655.39,OTHER, 225.62, 1207.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8660,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8661,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1813.70,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8662,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 979.64,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8663,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 305.20,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8664,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 64.40,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8665,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 737.37,,OUTPCT LIMIT, 547.41,OTHER, 138.71, 1032.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8666,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 169.11,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8667,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 169.11,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8668,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 204.77,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8669,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 204.77,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8670,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 428.66,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8671,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 562.10,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8672,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 617.40,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8673,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 428.66,,OUTPCT LIMIT, 332.46,OTHER, 140.42, 600.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8674,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 260.93,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8675,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 260.93,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8676,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 169.11,,OUTPCT LIMIT, 174.98,OTHER, 103.88, 239.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8677,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 169.11,,OUTPCT LIMIT, 136.10,OTHER, 76.16, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8678,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 121.10,,OUTPCT LIMIT, 140.33,OTHER, 74.39, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8679,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 297.50,,OUTPCT LIMIT, 228.33,OTHER, 87.35, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8680,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 37.34,,OUTPCT LIMIT, 34.19,OTHER, 22.94, 52.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8681,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 72.80,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8682,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 229.36,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8683,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 229.36,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8684,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 100.40,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8685,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 100.40,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8686,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 515.33,,OUTPCT LIMIT, 415.63,OTHER, 235.80, 721.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8687,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2275.00,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8688,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2275.00,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8689,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2730.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8690,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2730.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8691,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2730.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8692,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 189.85,,OUTPCT LIMIT, 152.82,OTHER, 85.61, 265.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8693,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 207.40,,OUTPCT LIMIT, 165.98,OTHER, 89.47, 290.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8694,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 336.19,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8695,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 336.19,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8696,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 126.14,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8697,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 126.14,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8698,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 400.16,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8699,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 400.16,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8700,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 400.16,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8701,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 115.29,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8702,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 115.34,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8703,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 137.50,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8704,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 137.50,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8705,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 100.76,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8706,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 100.76,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8707,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 107.72,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8708,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 107.72,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8709,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 41.65,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8710,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 41.65,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8711,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 210.59,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8712,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 210.59,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8713,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 119.65,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8714,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 119.65,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8715,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 120.75,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8716,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 120.75,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8717,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 61.57,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8718,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 61.57,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8719,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 67.58,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8720,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 67.58,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8721,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 74.05,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8722,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 74.05,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8723,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 74.05,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8724,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 294.00,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8725,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 94.40,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8726,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 94.40,,OUTPCT LIMIT, 72.71,OTHER, 28.82, 132.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8727,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 86.02,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8728,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 85.96,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8729,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 86.02,,OUTPCT LIMIT, 74.35,OTHER, 52.84, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8730,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 91.74,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8731,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 91.74,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8732,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 91.74,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8733,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 66.59,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8734,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 66.59,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8735,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 47.33,,OUTPCT LIMIT, 47.68,OTHER, 29.08, 66.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8736,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 125.30,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8737,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 125.30,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8738,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 125.30,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8739,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 150.50,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8740,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 150.50,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8741,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 150.50,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8742,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 85.87,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8743,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 85.87,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8744,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 85.87,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8745,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 30.80,,OUTPCT LIMIT, 30.33,OTHER, 18.92, 43.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8746,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 185.53,,OUTPCT LIMIT, 178.52,OTHER, 113.97, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8747,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 220.15,,OUTPCT LIMIT, 202.67,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8748,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 208.44,,OUTPCT LIMIT, 194.50,OTHER, 128.04, 291.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8749,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 103.85,,OUTPCT LIMIT, 106.37,OTHER, 63.79, 145.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8750,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 178.03,,OUTPCT LIMIT, 173.75,OTHER, 109.36, 249.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8751,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 188.19,,OUTPCT LIMIT, 180.83,OTHER, 115.60, 263.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8752,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 222.10,,OUTPCT LIMIT, 204.49,OTHER, 136.43, 310.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8753,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 107.27,,OUTPCT LIMIT, 108.91,OTHER, 65.89, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8754,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 84.50,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8755,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 84.50,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8756,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 84.50,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8757,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 51.38,,OUTPCT LIMIT, 44.69,OTHER, 31.56, 71.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8758,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 89.36,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8759,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 89.36,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8760,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 62.03,,OUTPCT LIMIT, 59.17,OTHER, 38.11, 86.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8761,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 81.20,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8762,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 81.20,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8763,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 81.20,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8764,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 20.30,,OUTPCT LIMIT, 68.90,OTHER, 12.81, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8765,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 100.63,,OUTPCT LIMIT, 93.12,OTHER, 61.82, 140.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8766,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 84.70,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8767,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 185.53,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8768,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 86.80,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8769,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 86.80,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8770,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 86.80,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8771,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 52.50,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8772,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 72.80,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8773,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 98.70,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8774,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 72.80,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8775,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 98.70,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8776,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 52.50,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8777,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 52.50,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8778,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 210.00,,OUTPCT LIMIT, 192.27,OTHER, 129.00, 294.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8779,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8780,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8781,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 169.11,,OUTPCT LIMIT, 145.27,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8782,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 104.13,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8783,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 104.13,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8784,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 176.45,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8785,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 176.45,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8786,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 276.08,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8787,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 276.08,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8788,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 343.91,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8789,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 343.91,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8790,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 33.32,,OUTPCT LIMIT, 30.51,OTHER, 20.47, 46.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8791,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 72.59,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8792,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 72.59,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8793,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 121.38,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8794,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 121.38,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8795,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 179.10,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8796,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 179.10,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8797,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 239.79,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8798,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 239.79,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8799,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 238.00,,OUTPCT LIMIT, 272.06,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8800,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 294.70,,OUTPCT LIMIT, 336.87,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8801,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 101.50,,OUTPCT LIMIT, 111.61,OTHER, 64.03, 142.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8802,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 123.90,,OUTPCT LIMIT, 149.82,OTHER, 78.16, 173.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8803,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 179.20,,OUTPCT LIMIT, 220.11,OTHER, 113.05, 250.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8804,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 188.24,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8805,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 188.24,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8806,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 175.70,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8807,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 175.70,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8808,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 291.20,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8809,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 291.20,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8810,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 207.20,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8811,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 207.20,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8812,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 460.14,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8813,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 460.14,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8814,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 238.00,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8815,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 238.00,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8816,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 721.75,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8817,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 721.75,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8818,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 294.70,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8819,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 294.70,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8820,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1203.85,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8821,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1203.85,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8822,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 350.70,,OUTPCT LIMIT, 429.06,OTHER, 221.24, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8823,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1925.55,,OUTPCT LIMIT, 1514.86,OTHER, 720.78, 2695.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8824,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 705.89,,OUTPCT LIMIT, 646.30,OTHER, 433.62, 988.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8825,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 21.00,,OUTPCT LIMIT, 19.23,OTHER, 12.90, 29.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8826,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 117.22,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8827,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 117.22,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8828,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 184.45,,OUTPCT LIMIT, 167.97,OTHER, 113.31, 258.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8829,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.19,,OUTPCT LIMIT, 173.37,OTHER, 118.06, 269.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8830,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 200.52,,OUTPCT LIMIT, 179.18,OTHER, 123.17, 280.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8831,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 226.70,,OUTPCT LIMIT, 197.44,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8832,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 220.15,,OUTPCT LIMIT, 192.88,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8833,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 254.07,,OUTPCT LIMIT, 232.62,OTHER, 156.07, 355.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8834,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 276.08,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8835,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 166.01,,OUTPCT LIMIT, 155.10,OTHER, 101.97, 232.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8836,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 177.31,,OUTPCT LIMIT, 162.99,OTHER, 108.92, 248.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8837,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 193.38,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8838,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 193.38,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8839,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 193.38,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8840,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 197.54,,OUTPCT LIMIT, 177.10,OTHER, 121.35, 276.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8841,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 210.63,,OUTPCT LIMIT, 192.85,OTHER, 129.39, 294.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8842,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 226.70,,OUTPCT LIMIT, 207.56,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8843,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 60.69,,OUTPCT LIMIT, 55.57,OTHER, 37.28, 84.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8844,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 104.13,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8845,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 49.00,,OUTPCT LIMIT, 44.86,OTHER, 30.10, 68.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8846,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 186.24,,OUTPCT LIMIT, 170.52,OTHER, 114.40, 260.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8847,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 37.02,,OUTPCT LIMIT, 33.14,OTHER, 22.74, 51.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8848,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 45.82,,OUTPCT LIMIT, 39.28,OTHER, 28.14, 64.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8849,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 66.07,,OUTPCT LIMIT, 60.49,OTHER, 40.58, 92.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8850,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 15.40,,OUTPCT LIMIT, 14.10,OTHER, 9.46, 21.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8851,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 15.40,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8852,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 104.13,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8853,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 178.50,,OUTPCT LIMIT, 148.65,OTHER, 101.33, 249.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8854,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.50,,OUTPCT LIMIT, 166.04,OTHER, 118.25, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8855,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 8.93,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8856,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 8.93,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8857,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 269.50,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8858,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 269.50,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8859,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 424.90,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8860,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 424.90,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8861,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 248.50,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8862,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 248.50,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8863,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 358.40,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8864,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 358.40,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8865,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 614.60,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8866,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 614.60,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8867,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 682.50,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8868,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 682.50,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8869,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 95.20,,OUTPCT LIMIT, 87.16,OTHER, 58.48, 133.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8870,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 44.80,,OUTPCT LIMIT, 41.02,OTHER, 27.52, 62.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8871,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 52.50,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8872,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2097.20,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8873,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2097.20,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8874,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2282.70,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8875,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2282.70,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8876,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1610.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8877,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1610.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8878,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1610.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8879,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1400.00,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8880,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1400.00,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8881,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1400.00,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8882,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1400.00,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8883,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 13.40,,OUTPCT LIMIT, 9.74,OTHER, 1.66, 18.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8884,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 78.86,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8885,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 4.20,,OUTPCT LIMIT, 11.82,OTHER, 2.58, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8886,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 63.07,,OUTPCT LIMIT, 57.75,OTHER, 38.74, 88.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8887,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 32.73,,OUTPCT LIMIT, 29.96,OTHER, 20.10, 45.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8888,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 115.72,,OUTPCT LIMIT, 88.75,OTHER, 33.71, 162.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8889,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 72.80,,OUTPCT LIMIT, 58.81,OTHER, 33.71, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8890,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 273.70,,OUTPCT LIMIT, 250.60,OTHER, 168.13, 383.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8891,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 276.08,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8892,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 276.08,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8893,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 29.75,,OUTPCT LIMIT, 35.44,OTHER, 18.28, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8894,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 42.84,,OUTPCT LIMIT, 44.57,OTHER, 26.32, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8895,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 47.60,,OUTPCT LIMIT, 43.58,OTHER, 29.24, 66.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8896,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8897,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 181.86,,OUTPCT LIMIT, 166.51,OTHER, 111.71, 254.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8898,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 65.64,,OUTPCT LIMIT, 60.10,OTHER, 40.32, 91.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8899,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 5.38,,OUTPCT LIMIT, 4.92,OTHER, 3.30, 7.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8900,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 5.21,,OUTPCT LIMIT, 4.77,OTHER, 3.20, 7.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8901,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 14.22,,OUTPCT LIMIT, 13.02,OTHER, 8.74, 19.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8902,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 147.00,,OUTPCT LIMIT, 134.59,OTHER, 90.30, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8903,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1.48,,OUTPCT LIMIT, 1.36,OTHER, .91, 2.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8904,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2.30,,OUTPCT LIMIT, 2.10,OTHER, 1.41, 3.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8905,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 28.30,,OUTPCT LIMIT, 25.91,OTHER, 17.38, 39.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8906,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 101.58,,OUTPCT LIMIT, 93.00,OTHER, 62.40, 142.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8907,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1.60,,OUTPCT LIMIT, 1.46,OTHER, .98, 2.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8908,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1.12,,OUTPCT LIMIT, 1.03,OTHER, .69, 1.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8909,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 5.63,,OUTPCT LIMIT, 5.15,OTHER, 3.46, 7.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8910,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 12.52,,OUTPCT LIMIT, 11.46,OTHER, 7.69, 17.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8911,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 4.79,,OUTPCT LIMIT, 4.38,OTHER, 2.94, 6.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8912,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2.80,,OUTPCT LIMIT, 2.56,OTHER, 1.72, 3.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8913,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 8.18,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8914,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 9.10,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8915,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 47.82,,OUTPCT LIMIT, 43.79,OTHER, 29.38, 66.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8916,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 25.14,,OUTPCT LIMIT, 23.02,OTHER, 15.45, 35.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8917,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 7.36,,OUTPCT LIMIT, 6.74,OTHER, 4.52, 10.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8918,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 5.68,,OUTPCT LIMIT, 5.20,OTHER, 3.49, 7.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8919,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 279.30,,OUTPCT LIMIT, 575.18,OTHER, 171.57, 1597.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8920,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 279.30,,OUTPCT LIMIT, 690.66,OTHER, 171.57, 2082.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8921,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 279.30,,OUTPCT LIMIT, 656.15,OTHER, 171.57, 1937.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8922,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 279.30,,OUTPCT LIMIT, 607.70,OTHER, 171.57, 1734.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8923,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 349.30,,OUTPCT LIMIT, 735.35,OTHER, 214.57, 2065.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8924,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 598.50,,OUTPCT LIMIT, 421.89,OTHER, 18.42, 837.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8925,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3.36,,OUTPCT LIMIT, 3.08,OTHER, 2.06, 4.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8926,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 243.60,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8927,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 243.60,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8928,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 243.60,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8929,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 243.60,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8930,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 243.60,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8931,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 243.60,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8932,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 243.60,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8933,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 243.60,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8934,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 243.60,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8935,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 243.60,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8936,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 243.60,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8937,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 243.60,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8938,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 290.50,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8939,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 290.50,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8940,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 290.50,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8941,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 290.50,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8942,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8943,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8944,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8945,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8946,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8947,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8948,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8949,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8950,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8951,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8952,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8953,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8954,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8955,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8956,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8957,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8958,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8959,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8960,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8961,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 928.20,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8962,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 74.38,,OUTPCT LIMIT, 62.01,OTHER, 42.53, 104.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8963,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 79.80,,OUTPCT LIMIT, 73.06,OTHER, 49.02, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8964,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 70.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8965,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 350.00,,OUTPCT LIMIT, 320.46,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8966,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 29.40,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8967,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2.10,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8968,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 24.50,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8969,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2.10,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8970,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 18.90,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8971,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2.10,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8972,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 10.50,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8973,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2.21,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8974,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 52.50,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8975,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2.21,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8976,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3.16,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8977,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 70.70,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8978,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 4.20,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8979,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 4.20,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8980,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 128.74,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8981,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 4.20,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8982,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 126.00,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8983,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 40.60,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8984,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 40.60,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8985,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 232.51,,OUTPCT LIMIT, 212.89,OTHER, 142.83, 325.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8986,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 85.25,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8987,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 52.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8988,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 689.24,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8989,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 501.93,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8990,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 6.30,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8991,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 4.20,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8992,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 70.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8993,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 70.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8994,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 70.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8995,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 70.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8996,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 70.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8997,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 70.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8998,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 70.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 8999,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 4.20,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9000,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 70.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9001,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 71.40,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9002,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 50.29,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9003,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 50.29,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9004,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 52.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9005,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 96.31,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9006,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2.10,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9007,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 10.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9008,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 10.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9009,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 10.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9010,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 12.60,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9011,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 16.80,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9012,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2.10,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9013,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 19.96,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9014,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 19.96,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9015,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 21.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9016,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 21.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9017,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 21.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9018,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 21.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9019,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2.10,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9020,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2.09,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9021,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 32.54,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9022,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 7.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9023,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 2.21,,OUTPCT LIMIT, 2.02,OTHER, 1.35, 3.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9024,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 350.70,,OUTPCT LIMIT, 321.10,OTHER, 215.43, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9025,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 400.40,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9026,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9027,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9028,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9029,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9030,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9031,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9032,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9033,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 23.82,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9034,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 106.53,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9035,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 99.85,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9036,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 65.23,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9037,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 59.88,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9038,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 182.20,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9039,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 5323.99,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9040,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 31.65,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9041,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1246.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9042,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1246.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9043,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1246.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9044,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1246.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9045,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1246.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9046,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1246.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9047,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1680.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9048,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1246.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9049,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1246.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9050,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1246.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9051,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1246.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9052,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1246.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9053,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 1246.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9054,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 980.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9055,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 980.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9056,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 980.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9057,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9058,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9059,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9060,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 73.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9061,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9062,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 46.99,,OUTPCT LIMIT, 43.03,OTHER, 28.87, 65.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9063,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 7.00,,OUTPCT LIMIT, 6.41,OTHER, 4.30, 9.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9064,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 4060.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9065,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3360.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9066,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3360.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9067,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 3360.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9068,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9069,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9070,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 305.20,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9071,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 205.95,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9072,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 212.32,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9073,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 172.98,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9074,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 192.19,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9075,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 396.90,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9076,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 121.38,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9077,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 70.70,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9078,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 71.16,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9079,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 104.13,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9080,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 11.90,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9081,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 19.60,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9082,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9083,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9084,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9085,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9086,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9087,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9088,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9089,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9090,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9091,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9092,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9093,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9094,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, 227.50,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9095,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,FRIDAY_HEALTH_PLAN,FRIDAY HEALTH PLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9096,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,HUMANA,HUMANA COMMERCIAL, 1127.00,,OUTPCT LIMIT, 920.20,OTHER, 507.84, 1127.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9097,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,HUMANA,HUMANA COMMERCIAL, 833.00,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9098,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,HUMANA,HUMANA COMMERCIAL, 1347.50,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9099,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9100,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9101,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9102,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9103,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9104,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9105,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9106,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9107,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9108,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9109,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9110,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9111,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9112,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9113,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9114,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,HUMANA,HUMANA COMMERCIAL, 477.06,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9115,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,HUMANA,HUMANA COMMERCIAL, 477.06,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9116,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,HUMANA,HUMANA COMMERCIAL, 270.73,,OUTPCT LIMIT, 168.89,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9117,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,HUMANA,HUMANA COMMERCIAL, 229.32,,OUTPCT LIMIT, 171.36,OTHER, 103.33, 229.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9118,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,HUMANA,HUMANA COMMERCIAL, 481.41,,OUTPCT LIMIT, 273.87,OTHER, 142.76, 481.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9119,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,HUMANA,HUMANA COMMERCIAL, 430.22,,OUTPCT LIMIT, 276.81,OTHER, 142.76, 430.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9120,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,HUMANA,HUMANA COMMERCIAL, 354.86,,OUTPCT LIMIT, 242.16,OTHER, 155.70, 354.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9121,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,HUMANA,HUMANA COMMERCIAL, 451.78,,OUTPCT LIMIT, 850.02,OTHER, 203.58, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9122,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,HUMANA,HUMANA COMMERCIAL, 430.22,,OUTPCT LIMIT, 667.92,OTHER, 193.86, 1237.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9123,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,HUMANA,HUMANA COMMERCIAL, 150.92,,OUTPCT LIMIT, 177.23,OTHER, 68.01, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9124,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,HUMANA,HUMANA COMMERCIAL, 68.60,,OUTPCT LIMIT, 131.69,OTHER, 30.91, 267.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9125,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,HUMANA,HUMANA COMMERCIAL, 124.46,,OUTPCT LIMIT, 116.49,OTHER, 56.08, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9126,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,HUMANA,HUMANA COMMERCIAL, 597.80,,OUTPCT LIMIT, 405.48,OTHER, 256.74, 597.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9127,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,HUMANA,HUMANA COMMERCIAL, 359.66,,OUTPCT LIMIT, 293.67,OTHER, 162.07, 359.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9128,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,HUMANA,HUMANA COMMERCIAL, 238.14,,OUTPCT LIMIT, 216.69,OTHER, 107.31, 256.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9129,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,HUMANA,HUMANA COMMERCIAL, 75.46,,OUTPCT LIMIT, 61.61,OTHER, 34.00, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9130,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,HUMANA,HUMANA COMMERCIAL, 134.26,,OUTPCT LIMIT, 233.68,OTHER, 60.50, 456.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9131,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,HUMANA,HUMANA COMMERCIAL, 204.82,,OUTPCT LIMIT, 158.67,OTHER, 92.29, 204.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9132,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,HUMANA,HUMANA COMMERCIAL, 155.82,,OUTPCT LIMIT, 112.58,OTHER, 70.21, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9133,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,HUMANA,HUMANA COMMERCIAL, 180.32,,OUTPCT LIMIT, 125.44,OTHER, 81.25, 180.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9134,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,HUMANA,HUMANA COMMERCIAL, 114.66,,OUTPCT LIMIT, 114.17,OTHER, 51.67, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9135,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,HUMANA,HUMANA COMMERCIAL, 135.24,,OUTPCT LIMIT, 122.15,OTHER, 60.94, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9136,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,HUMANA,HUMANA COMMERCIAL, 205.80,,OUTPCT LIMIT, 138.81,OTHER, 86.20, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9137,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,HUMANA,HUMANA COMMERCIAL, 164.64,,OUTPCT LIMIT, 117.21,OTHER, 74.19, 164.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9138,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,HUMANA,HUMANA COMMERCIAL, 200.90,,OUTPCT LIMIT, 258.26,OTHER, 90.53, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9139,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,HUMANA,HUMANA COMMERCIAL, 256.76,,OUTPCT LIMIT, 287.58,OTHER, 115.70, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9140,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,HUMANA,HUMANA COMMERCIAL, 345.94,,OUTPCT LIMIT, 334.39,OTHER, 155.88, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9141,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,HUMANA,HUMANA COMMERCIAL, 2338.28,,OUTPCT LIMIT, 1514.68,OTHER, 804.50, 2338.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9142,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,HUMANA,HUMANA COMMERCIAL, 1321.04,,OUTPCT LIMIT, 1306.30,OTHER, 595.28, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9143,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,HUMANA,HUMANA COMMERCIAL, 595.84,,OUTPCT LIMIT, 925.64,OTHER, 268.49, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9144,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,HUMANA,HUMANA COMMERCIAL, 195.02,,OUTPCT LIMIT, 389.69,OTHER, 87.88, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9145,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,HUMANA,HUMANA COMMERCIAL, 266.56,,OUTPCT LIMIT, 427.24,OTHER, 120.12, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9146,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,HUMANA,HUMANA COMMERCIAL, 324.38,,OUTPCT LIMIT, 457.59,OTHER, 146.17, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9147,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,HUMANA,HUMANA COMMERCIAL, 228.34,,OUTPCT LIMIT, 732.74,OTHER, 102.89, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9148,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,HUMANA,HUMANA COMMERCIAL, 665.42,,OUTPCT LIMIT, 1168.49,OTHER, 299.85, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9149,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,HUMANA,HUMANA COMMERCIAL, 281.26,,OUTPCT LIMIT, 300.44,OTHER, 126.74, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9150,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,HUMANA,HUMANA COMMERCIAL, 395.92,,OUTPCT LIMIT, 495.14,OTHER, 178.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9151,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,HUMANA,HUMANA COMMERCIAL, 471.38,,OUTPCT LIMIT, 534.75,OTHER, 212.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9152,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,HUMANA,HUMANA COMMERCIAL, 543.90,,OUTPCT LIMIT, 572.81,OTHER, 245.09, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9153,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,HUMANA,HUMANA COMMERCIAL, 485.10,,OUTPCT LIMIT, 541.95,OTHER, 218.59, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9154,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,HUMANA,HUMANA COMMERCIAL, 555.66,,OUTPCT LIMIT, 578.99,OTHER, 250.39, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9155,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,HUMANA,HUMANA COMMERCIAL, 1701.28,,OUTPCT LIMIT, 1505.88,OTHER, 766.62, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9156,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,HUMANA,HUMANA COMMERCIAL, 685.02,,OUTPCT LIMIT, 646.89,OTHER, 308.68, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9157,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,HUMANA,HUMANA COMMERCIAL, 806.54,,OUTPCT LIMIT, 1242.56,OTHER, 363.44, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9158,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,HUMANA,HUMANA COMMERCIAL, 430.22,,OUTPCT LIMIT, 513.14,OTHER, 193.86, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9159,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,HUMANA,HUMANA COMMERCIAL, 444.92,,OUTPCT LIMIT, 520.86,OTHER, 200.49, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9160,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,HUMANA,HUMANA COMMERCIAL, 776.16,,OUTPCT LIMIT, 694.73,OTHER, 349.75, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9161,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,HUMANA,HUMANA COMMERCIAL, 637.98,,OUTPCT LIMIT, 947.76,OTHER, 287.48, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9162,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,HUMANA,HUMANA COMMERCIAL, 1093.68,,OUTPCT LIMIT, 1393.28,OTHER, 492.83, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9163,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,HUMANA,HUMANA COMMERCIAL, 54.88,,OUTPCT LIMIT, 56.01,OTHER, 24.73, 76.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9164,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,HUMANA,HUMANA COMMERCIAL, 331.14,,OUTPCT LIMIT, 185.53,OTHER, 86.20, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9165,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,HUMANA,HUMANA COMMERCIAL, 126.69,,OUTPCT LIMIT, 97.29,OTHER, 57.09, 126.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9166,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,HUMANA,HUMANA COMMERCIAL, 126.42,,OUTPCT LIMIT, 97.14,OTHER, 56.97, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9167,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,HUMANA,HUMANA COMMERCIAL, 49.98,,OUTPCT LIMIT, 57.02,OTHER, 22.52, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9168,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,HUMANA,HUMANA COMMERCIAL, 419.44,,OUTPCT LIMIT, 372.97,OTHER, 189.00, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9169,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,HUMANA,HUMANA COMMERCIAL, 1195.60,,OUTPCT LIMIT, 1446.78,OTHER, 538.75, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9170,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,HUMANA,HUMANA COMMERCIAL, 576.24,,OUTPCT LIMIT, 1121.68,OTHER, 259.66, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9171,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,HUMANA,HUMANA COMMERCIAL, 376.07,,OUTPCT LIMIT, 278.63,OTHER, 165.01, 383.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9172,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,HUMANA,HUMANA COMMERCIAL, 675.06,,OUTPCT LIMIT, 427.61,OTHER, 296.20, 675.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9173,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,HUMANA,HUMANA COMMERCIAL, 408.51,,OUTPCT LIMIT, 237.66,OTHER, 143.26, 408.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9174,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,HUMANA,HUMANA COMMERCIAL, 440.61,,OUTPCT LIMIT, 253.66,OTHER, 143.26, 440.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9175,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,HUMANA,HUMANA COMMERCIAL, 477.75,,OUTPCT LIMIT, 272.17,OTHER, 143.26, 477.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9176,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,HUMANA,HUMANA COMMERCIAL, 436.07,,OUTPCT LIMIT, 251.39,OTHER, 143.26, 436.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9177,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,HUMANA,HUMANA COMMERCIAL, 400.82,,OUTPCT LIMIT, 261.55,OTHER, 143.26, 400.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9178,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,HUMANA,HUMANA COMMERCIAL, 462.48,,OUTPCT LIMIT, 264.56,OTHER, 143.26, 462.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9179,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,HUMANA,HUMANA COMMERCIAL, 467.17,,OUTPCT LIMIT, 306.35,OTHER, 204.98, 467.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9180,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,HUMANA,HUMANA COMMERCIAL, 833.98,,OUTPCT LIMIT, 548.12,OTHER, 309.01, 833.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9181,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,HUMANA,HUMANA COMMERCIAL, 482.16,,OUTPCT LIMIT, 300.52,OTHER, 132.82, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9182,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,HUMANA,HUMANA COMMERCIAL, 524.72,,OUTPCT LIMIT, 293.08,OTHER, 132.82, 524.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9183,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,HUMANA,HUMANA COMMERCIAL, 1906.94,,OUTPCT LIMIT, 1023.77,OTHER, 309.01, 1906.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9184,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,HUMANA,HUMANA COMMERCIAL, 738.92,,OUTPCT LIMIT, 498.22,OTHER, 309.01, 738.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9185,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,HUMANA,HUMANA COMMERCIAL, 3210.73,,OUTPCT LIMIT, 1703.49,OTHER, 435.32, 3210.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9186,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,HUMANA,HUMANA COMMERCIAL, 849.66,,OUTPCT LIMIT, 601.46,OTHER, 382.87, 849.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9187,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,HUMANA,HUMANA COMMERCIAL, 2648.94,,OUTPCT LIMIT, 2228.68,OTHER, 1193.64, 2648.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9188,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,HUMANA,HUMANA COMMERCIAL, 2877.28,,OUTPCT LIMIT, 2329.49,OTHER, 1296.54, 2877.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9189,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,HUMANA,HUMANA COMMERCIAL, 125.44,,OUTPCT LIMIT, 163.86,OTHER, 56.52, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9190,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,HUMANA,HUMANA COMMERCIAL, 331.14,,OUTPCT LIMIT, 200.99,OTHER, 145.30, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9191,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,HUMANA,HUMANA COMMERCIAL, 118.58,,OUTPCT LIMIT, 93.03,OTHER, 53.43, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9192,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,HUMANA,HUMANA COMMERCIAL, 12.74,,OUTPCT LIMIT, 22.22,OTHER, 5.74, 43.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9193,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,HUMANA,HUMANA COMMERCIAL, 325.36,,OUTPCT LIMIT, 224.77,OTHER, 146.61, 325.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9194,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,HUMANA,HUMANA COMMERCIAL, 172.48,,OUTPCT LIMIT, 251.63,OTHER, 77.72, 451.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9195,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,HUMANA,HUMANA COMMERCIAL, 536.06,,OUTPCT LIMIT, 1148.36,OTHER, 241.56, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9196,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,HUMANA,HUMANA COMMERCIAL, 1271.06,,OUTPCT LIMIT, 1534.16,OTHER, 572.76, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9197,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,HUMANA,HUMANA COMMERCIAL, 271.46,,OUTPCT LIMIT, 232.01,OTHER, 122.32, 271.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9198,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,HUMANA,HUMANA COMMERCIAL, 129.95,,OUTPCT LIMIT, 124.43,OTHER, 57.02, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9199,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,HUMANA,HUMANA COMMERCIAL, 121.52,,OUTPCT LIMIT, 120.23,OTHER, 53.32, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9200,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,HUMANA,HUMANA COMMERCIAL, 141.61,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9201,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,HUMANA,HUMANA COMMERCIAL, 141.61,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9202,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,HUMANA,HUMANA COMMERCIAL, 8355.48,,OUTPCT LIMIT, 5204.99,OTHER, 2293.79, 8355.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9203,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,HUMANA,HUMANA COMMERCIAL, 609.56,,OUTPCT LIMIT, 932.84,OTHER, 274.68, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9204,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,HUMANA,HUMANA COMMERCIAL, 774.40,,OUTPCT LIMIT, 424.57,OTHER, 162.56, 774.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9205,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,HUMANA,HUMANA COMMERCIAL, 594.42,,OUTPCT LIMIT, 334.89,OTHER, 162.56, 594.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9206,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,HUMANA,HUMANA COMMERCIAL, 1131.73,,OUTPCT LIMIT, 675.88,OTHER, 470.23, 1131.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9207,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,HUMANA,HUMANA COMMERCIAL, 925.32,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9208,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,HUMANA,HUMANA COMMERCIAL, 925.32,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9209,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,HUMANA,HUMANA COMMERCIAL, 339.13,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9210,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,HUMANA,HUMANA COMMERCIAL, 339.13,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9211,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,HUMANA,HUMANA COMMERCIAL, 305.24,,OUTPCT LIMIT, 176.70,OTHER, 103.34, 305.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9212,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,HUMANA,HUMANA COMMERCIAL, 1107.35,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9213,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,HUMANA,HUMANA COMMERCIAL, 1107.35,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9214,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,HUMANA,HUMANA COMMERCIAL, 1926.62,,OUTPCT LIMIT, 1089.64,OTHER, 544.52, 1926.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9215,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,HUMANA,HUMANA COMMERCIAL, 34.30,,OUTPCT LIMIT, 22.43,OTHER, 15.05, 34.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9216,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,HUMANA,HUMANA COMMERCIAL, 30.43,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9217,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,HUMANA,HUMANA COMMERCIAL, 30.43,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9218,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,HUMANA,HUMANA COMMERCIAL, 30.43,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9219,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,HUMANA,HUMANA COMMERCIAL, 30.43,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9220,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,HUMANA,HUMANA COMMERCIAL, 30.43,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9221,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,HUMANA,HUMANA COMMERCIAL, 30.43,,OUTPCT LIMIT, 20.38,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9222,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,HUMANA,HUMANA COMMERCIAL, 24.50,,OUTPCT LIMIT, 16.02,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9223,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,HUMANA,HUMANA COMMERCIAL, 1003.63,,OUTPCT LIMIT, 579.04,OTHER, 331.58, 1003.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9224,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,HUMANA,HUMANA COMMERCIAL, 2161.88,,OUTPCT LIMIT, 1525.88,OTHER, 974.17, 2161.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9225,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,HUMANA,HUMANA COMMERCIAL, 6115.20,,OUTPCT LIMIT, 4097.24,OTHER, 2484.68, 6115.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9226,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,HUMANA,HUMANA COMMERCIAL, 6504.26,,OUTPCT LIMIT, 4480.28,OTHER, 2930.90, 6504.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9227,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,HUMANA,HUMANA COMMERCIAL, 804.58,,OUTPCT LIMIT, 813.44,OTHER, 362.55, 1095.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9228,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,HUMANA,HUMANA COMMERCIAL, 7048.16,,OUTPCT LIMIT, 4090.68,OTHER, 1095.12, 7048.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9229,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,HUMANA,HUMANA COMMERCIAL, 236.76,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9230,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,HUMANA,HUMANA COMMERCIAL, 236.76,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9231,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,HUMANA,HUMANA COMMERCIAL, 619.36,,OUTPCT LIMIT, 1187.28,OTHER, 279.09, 2414.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9232,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,HUMANA,HUMANA COMMERCIAL, 383.18,,OUTPCT LIMIT, 803.17,OTHER, 172.67, 1685.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9233,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,HUMANA,HUMANA COMMERCIAL, 2155.02,,OUTPCT LIMIT, 1733.21,OTHER, 971.08, 2155.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9234,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,HUMANA,HUMANA COMMERCIAL, 2765.56,,OUTPCT LIMIT, 1757.99,OTHER, 857.80, 2765.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9235,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,HUMANA,HUMANA COMMERCIAL, 326.34,,OUTPCT LIMIT, 477.65,OTHER, 147.05, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9236,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,HUMANA,HUMANA COMMERCIAL, 364.56,,OUTPCT LIMIT, 497.71,OTHER, 164.28, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9237,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,HUMANA,HUMANA COMMERCIAL, 2302.02,,OUTPCT LIMIT, 1514.68,OTHER, 857.80, 2302.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9238,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,HUMANA,HUMANA COMMERCIAL, 3252.62,,OUTPCT LIMIT, 2013.65,OTHER, 857.80, 3252.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9239,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,HUMANA,HUMANA COMMERCIAL, 463.54,,OUTPCT LIMIT, 549.67,OTHER, 208.88, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9240,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,HUMANA,HUMANA COMMERCIAL, 518.42,,OUTPCT LIMIT, 578.48,OTHER, 233.61, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9241,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,HUMANA,HUMANA COMMERCIAL, 2700.88,,OUTPCT LIMIT, 2205.29,OTHER, 1217.05, 2700.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9242,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,HUMANA,HUMANA COMMERCIAL, 3307.50,,OUTPCT LIMIT, 2700.60,OTHER, 1490.40, 3307.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9243,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,HUMANA,HUMANA COMMERCIAL, 1142.91,,OUTPCT LIMIT, 718.33,OTHER, 501.48, 1142.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9244,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,HUMANA,HUMANA COMMERCIAL, 2985.08,,OUTPCT LIMIT, 2437.34,OTHER, 1345.11, 2985.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9245,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,HUMANA,HUMANA COMMERCIAL, 1578.78,,OUTPCT LIMIT, 1780.93,OTHER, 711.42, 2666.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9246,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,HUMANA,HUMANA COMMERCIAL, 1469.02,,OUTPCT LIMIT, 2411.76,OTHER, 661.96, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9247,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,HUMANA,HUMANA COMMERCIAL, 154.84,,OUTPCT LIMIT, 283.55,OTHER, 69.77, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9248,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,HUMANA,HUMANA COMMERCIAL, 184.24,,OUTPCT LIMIT, 298.98,OTHER, 83.02, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9249,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,HUMANA,HUMANA COMMERCIAL, 302.82,,OUTPCT LIMIT, 482.77,OTHER, 136.45, 906.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9250,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,HUMANA,HUMANA COMMERCIAL, 542.92,,OUTPCT LIMIT, 603.90,OTHER, 244.65, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9251,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,HUMANA,HUMANA COMMERCIAL, 636.02,,OUTPCT LIMIT, 652.77,OTHER, 286.60, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9252,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,HUMANA,HUMANA COMMERCIAL, 829.08,,OUTPCT LIMIT, 754.11,OTHER, 373.59, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9253,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,HUMANA,HUMANA COMMERCIAL, 756.56,,OUTPCT LIMIT, 716.04,OTHER, 340.92, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9254,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,HUMANA,HUMANA COMMERCIAL, 729.12,,OUTPCT LIMIT, 701.64,OTHER, 328.55, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9255,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,HUMANA,HUMANA COMMERCIAL, 3726.94,,OUTPCT LIMIT, 2366.55,OTHER, 1148.80, 3726.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9256,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,HUMANA,HUMANA COMMERCIAL, 245.98,,OUTPCT LIMIT, 623.49,OTHER, 110.84, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9257,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,HUMANA,HUMANA COMMERCIAL, 353.78,,OUTPCT LIMIT, 256.43,OTHER, 159.42, 353.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9258,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,HUMANA,HUMANA COMMERCIAL, 272.44,,OUTPCT LIMIT, 637.38,OTHER, 122.76, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9259,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,HUMANA,HUMANA COMMERCIAL, 272.44,,OUTPCT LIMIT, 982.61,OTHER, 122.76, 2350.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9260,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,HUMANA,HUMANA COMMERCIAL, 1452.36,,OUTPCT LIMIT, 1507.20,OTHER, 654.45, 2085.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9261,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,HUMANA,HUMANA COMMERCIAL, 3668.14,,OUTPCT LIMIT, 3143.54,OTHER, 1652.91, 3668.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9262,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,HUMANA,HUMANA COMMERCIAL, 1611.12,,OUTPCT LIMIT, 2486.35,OTHER, 725.99, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9263,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,HUMANA,HUMANA COMMERCIAL, 1751.26,,OUTPCT LIMIT, 2559.90,OTHER, 789.14, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9264,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,HUMANA,HUMANA COMMERCIAL, 1745.38,,OUTPCT LIMIT, 1425.12,OTHER, 786.49, 1745.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9265,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,HUMANA,HUMANA COMMERCIAL, 2808.68,,OUTPCT LIMIT, 1667.02,OTHER, 539.71, 2808.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9266,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,HUMANA,HUMANA COMMERCIAL, 1270.08,,OUTPCT LIMIT, 1786.42,OTHER, 572.31, 3135.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9267,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,HUMANA,HUMANA COMMERCIAL, 3471.16,,OUTPCT LIMIT, 3662.54,OTHER, 1564.15, 5153.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9268,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,HUMANA,HUMANA COMMERCIAL, 358.68,,OUTPCT LIMIT, 889.66,OTHER, 161.63, 1963.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9269,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,HUMANA,HUMANA COMMERCIAL, 394.89,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9270,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,HUMANA,HUMANA COMMERCIAL, 394.89,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9271,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,HUMANA,HUMANA COMMERCIAL, 2669.52,,OUTPCT LIMIT, 2146.09,OTHER, 1202.92, 2669.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9272,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 199.77,OTHER, 96.75, 377.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9273,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 266.50,OTHER, 96.75, 657.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9274,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,HUMANA,HUMANA COMMERCIAL, 3369.24,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9275,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,HUMANA,HUMANA COMMERCIAL, 3369.24,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9276,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,HUMANA,HUMANA COMMERCIAL, 1100.39,,OUTPCT LIMIT, 719.65,OTHER, 482.83, 1100.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9277,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,HUMANA,HUMANA COMMERCIAL, 1968.38,,OUTPCT LIMIT, 1287.31,OTHER, 863.68, 1968.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9278,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,HUMANA,HUMANA COMMERCIAL, 444.82,,OUTPCT LIMIT, 290.91,OTHER, 195.18, 444.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9279,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,HUMANA,HUMANA COMMERCIAL, 1660.12,,OUTPCT LIMIT, 2579.17,OTHER, 748.07, 4781.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9280,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,HUMANA,HUMANA COMMERCIAL, 255.90,,OUTPCT LIMIT, 162.43,OTHER, 112.28, 255.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9281,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,HUMANA,HUMANA COMMERCIAL, 221.56,,OUTPCT LIMIT, 145.32,OTHER, 97.21, 221.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9282,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,HUMANA,HUMANA COMMERCIAL, 141.51,,OUTPCT LIMIT, 116.13,OTHER, 62.09, 191.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9283,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,HUMANA,HUMANA COMMERCIAL, 116.62,,OUTPCT LIMIT, 76.24,OTHER, 51.17, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9284,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,HUMANA,HUMANA COMMERCIAL, 208.80,,OUTPCT LIMIT, 124.60,OTHER, 86.34, 208.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9285,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9286,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,HUMANA,HUMANA COMMERCIAL, 84.28,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9287,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9288,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,HUMANA,HUMANA COMMERCIAL, 134.26,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9289,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9290,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,HUMANA,HUMANA COMMERCIAL, 257.99,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9291,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9292,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,HUMANA,HUMANA COMMERCIAL, 84.28,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9293,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9294,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,HUMANA,HUMANA COMMERCIAL, 279.07,,OUTPCT LIMIT, 171.96,OTHER, 122.45, 279.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9295,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9296,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,HUMANA,HUMANA COMMERCIAL, 215.11,,OUTPCT LIMIT, 127.74,OTHER, 86.34, 215.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9297,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9298,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,HUMANA,HUMANA COMMERCIAL, 314.44,,OUTPCT LIMIT, 189.58,OTHER, 137.97, 314.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9299,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9300,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,HUMANA,HUMANA COMMERCIAL, 193.38,,OUTPCT LIMIT, 116.92,OTHER, 84.85, 193.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9301,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9302,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,HUMANA,HUMANA COMMERCIAL, 535.11,,OUTPCT LIMIT, 299.54,OTHER, 138.19, 535.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9303,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9304,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,HUMANA,HUMANA COMMERCIAL, 377.57,,OUTPCT LIMIT, 221.04,OTHER, 138.19, 377.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9305,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9306,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,HUMANA,HUMANA COMMERCIAL, 290.08,,OUTPCT LIMIT, 177.44,OTHER, 127.28, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9307,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9308,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,HUMANA,HUMANA COMMERCIAL, 101.66,,OUTPCT LIMIT, 71.21,OTHER, 44.60, 101.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9309,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9310,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,HUMANA,HUMANA COMMERCIAL, 347.19,,OUTPCT LIMIT, 193.56,OTHER, 86.34, 347.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9311,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9312,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,HUMANA,HUMANA COMMERCIAL, 407.29,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9313,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,HUMANA,HUMANA COMMERCIAL, 2869.58,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9314,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,HUMANA,HUMANA COMMERCIAL, 2132.95,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9315,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9316,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9317,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,HUMANA,HUMANA COMMERCIAL, 2193.83,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9318,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,HUMANA,HUMANA COMMERCIAL, 2193.83,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9319,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9320,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9321,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,HUMANA,HUMANA COMMERCIAL, 2869.58,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9322,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,HUMANA,HUMANA COMMERCIAL, 2869.58,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9323,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9324,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9325,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,HUMANA,HUMANA COMMERCIAL, 1781.38,,OUTPCT LIMIT, 955.20,OTHER, 283.82, 1781.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9326,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9327,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,HUMANA,HUMANA COMMERCIAL, 1180.96,,OUTPCT LIMIT, 691.35,OTHER, 432.18, 1180.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9328,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9329,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,HUMANA,HUMANA COMMERCIAL, 1548.40,,OUTPCT LIMIT, 887.08,OTHER, 485.27, 1548.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9330,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9331,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,HUMANA,HUMANA COMMERCIAL, 1672.86,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9332,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,HUMANA,HUMANA COMMERCIAL, 1673.23,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9333,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9334,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9335,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,HUMANA,HUMANA COMMERCIAL, 1912.64,,OUTPCT LIMIT, 1055.93,OTHER, 432.18, 1912.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9336,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,HUMANA,HUMANA COMMERCIAL, 2407.85,,OUTPCT LIMIT, 1302.68,OTHER, 432.18, 2407.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9337,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9338,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9339,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,HUMANA,HUMANA COMMERCIAL, 797.72,,OUTPCT LIMIT, 513.03,OTHER, 350.02, 797.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9340,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9341,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,HUMANA,HUMANA COMMERCIAL, 2454.47,,OUTPCT LIMIT, 1290.59,OTHER, 283.82, 2454.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9342,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9343,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,HUMANA,HUMANA COMMERCIAL, 2552.61,,OUTPCT LIMIT, 1374.81,OTHER, 432.18, 2552.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9344,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9345,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,HUMANA,HUMANA COMMERCIAL, 2308.78,,OUTPCT LIMIT, 1265.96,OTHER, 485.27, 2308.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9346,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9347,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,HUMANA,HUMANA COMMERCIAL, 1923.01,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9348,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,HUMANA,HUMANA COMMERCIAL, 1923.01,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9349,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,HUMANA,HUMANA COMMERCIAL, 1923.01,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9350,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9351,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9352,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9353,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,HUMANA,HUMANA COMMERCIAL, 2313.68,,OUTPCT LIMIT, 1270.81,OTHER, 495.38, 2313.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9354,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9355,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,HUMANA,HUMANA COMMERCIAL, 3002.40,,OUTPCT LIMIT, 1681.52,OTHER, 779.04, 3002.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9356,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9357,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,HUMANA,HUMANA COMMERCIAL, 2215.18,,OUTPCT LIMIT, 1224.87,OTHER, 508.57, 2215.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9358,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9359,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,HUMANA,HUMANA COMMERCIAL, 2362.78,,OUTPCT LIMIT, 1324.21,OTHER, 616.91, 2362.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9360,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9361,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,HUMANA,HUMANA COMMERCIAL, 2704.31,,OUTPCT LIMIT, 1532.99,OTHER, 779.04, 2704.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9362,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9363,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,HUMANA,HUMANA COMMERCIAL, 2232.69,,OUTPCT LIMIT, 1233.59,OTHER, 508.57, 2232.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9364,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9365,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,HUMANA,HUMANA COMMERCIAL, 2226.56,,OUTPCT LIMIT, 1256.33,OTHER, 616.91, 2226.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9366,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9367,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,HUMANA,HUMANA COMMERCIAL, 2560.01,,OUTPCT LIMIT, 1461.09,OTHER, 779.04, 2560.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9368,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9369,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,HUMANA,HUMANA COMMERCIAL, 2594.07,,OUTPCT LIMIT, 1413.66,OTHER, 508.57, 2594.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9370,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9371,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,HUMANA,HUMANA COMMERCIAL, 4005.18,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9372,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,HUMANA,HUMANA COMMERCIAL, 4005.18,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9373,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9374,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9375,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,HUMANA,HUMANA COMMERCIAL, 84.28,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9376,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,HUMANA,HUMANA COMMERCIAL, 84.28,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9377,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,HUMANA,HUMANA COMMERCIAL, 84.28,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9378,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,HUMANA,HUMANA COMMERCIAL, 84.28,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9379,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9380,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9381,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9382,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9383,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,HUMANA,HUMANA COMMERCIAL, 84.28,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9384,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9385,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,HUMANA,HUMANA COMMERCIAL, 84.28,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9386,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,HUMANA,HUMANA COMMERCIAL, 84.28,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9387,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9388,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9389,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,HUMANA,HUMANA COMMERCIAL, 444.52,,OUTPCT LIMIT, 242.05,OTHER, 86.34, 444.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9390,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,HUMANA,HUMANA COMMERCIAL, 447.46,,OUTPCT LIMIT, 243.52,OTHER, 86.34, 447.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9391,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9392,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9393,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,HUMANA,HUMANA COMMERCIAL, 363.72,,OUTPCT LIMIT, 214.14,OTHER, 138.19, 363.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9394,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,HUMANA,HUMANA COMMERCIAL, 415.68,,OUTPCT LIMIT, 240.03,OTHER, 138.19, 415.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9395,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9396,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9397,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,HUMANA,HUMANA COMMERCIAL, 433.42,,OUTPCT LIMIT, 248.87,OTHER, 138.19, 433.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9398,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9399,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,HUMANA,HUMANA COMMERCIAL, 290.08,,OUTPCT LIMIT, 165.10,OTHER, 86.34, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9400,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9401,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,HUMANA,HUMANA COMMERCIAL, 84.28,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9402,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9403,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,HUMANA,HUMANA COMMERCIAL, 2295.55,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9404,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,HUMANA,HUMANA COMMERCIAL, 2295.55,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9405,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,HUMANA,HUMANA COMMERCIAL, 2295.55,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9406,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9407,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9408,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,HUMANA,HUMANA COMMERCIAL, 2295.55,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9409,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,HUMANA,HUMANA COMMERCIAL, 2737.65,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9410,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9411,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,HUMANA,HUMANA COMMERCIAL, 3415.16,,OUTPCT LIMIT, 1817.25,OTHER, 485.27, 3415.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9412,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9413,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,HUMANA,HUMANA COMMERCIAL, 2295.55,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9414,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,HUMANA,HUMANA COMMERCIAL, 2295.55,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9415,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,HUMANA,HUMANA COMMERCIAL, 2295.55,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9416,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9417,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9418,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9419,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,HUMANA,HUMANA COMMERCIAL, 4880.43,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9420,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,HUMANA,HUMANA COMMERCIAL, 3288.57,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9421,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,HUMANA,HUMANA COMMERCIAL, 3288.57,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9422,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,HUMANA,HUMANA COMMERCIAL, 3288.57,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9423,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,HUMANA,HUMANA COMMERCIAL, 3288.57,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9424,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9425,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9426,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9427,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9428,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,HUMANA,HUMANA COMMERCIAL, 1240.68,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9429,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,HUMANA,HUMANA COMMERCIAL, 2768.50,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9430,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9431,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9432,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,HUMANA,HUMANA COMMERCIAL, 297.92,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9433,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,HUMANA,HUMANA COMMERCIAL, 297.92,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9434,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9435,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9436,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,HUMANA,HUMANA COMMERCIAL, 430.98,,OUTPCT LIMIT, 247.65,OTHER, 138.19, 430.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9437,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9438,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,HUMANA,HUMANA COMMERCIAL, 637.59,,OUTPCT LIMIT, 350.60,OTHER, 138.19, 637.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9439,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9440,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,HUMANA,HUMANA COMMERCIAL, 701.87,,OUTPCT LIMIT, 382.63,OTHER, 138.19, 701.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9441,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9442,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,HUMANA,HUMANA COMMERCIAL, 522.99,,OUTPCT LIMIT, 293.50,OTHER, 138.19, 522.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9443,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9444,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,HUMANA,HUMANA COMMERCIAL, 467.52,,OUTPCT LIMIT, 265.86,OTHER, 138.19, 467.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9445,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9446,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,HUMANA,HUMANA COMMERCIAL, 257.99,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9447,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9448,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,HUMANA,HUMANA COMMERCIAL, 245.00,,OUTPCT LIMIT, 142.64,OTHER, 86.34, 245.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9449,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9450,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,HUMANA,HUMANA COMMERCIAL, 84.28,,OUTPCT LIMIT, 63.06,OTHER, 36.98, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9451,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,HUMANA,HUMANA COMMERCIAL, 257.99,,OUTPCT LIMIT, 163.44,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9452,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9453,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,HUMANA,HUMANA COMMERCIAL, 454.23,,OUTPCT LIMIT, 259.24,OTHER, 138.19, 454.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9454,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9455,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,HUMANA,HUMANA COMMERCIAL, 268.93,,OUTPCT LIMIT, 166.91,OTHER, 118.00, 268.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9456,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9457,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,HUMANA,HUMANA COMMERCIAL, 750.94,,OUTPCT LIMIT, 407.08,OTHER, 138.19, 750.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9458,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9459,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,HUMANA,HUMANA COMMERCIAL, 2793.21,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9460,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,HUMANA,HUMANA COMMERCIAL, 2793.21,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9461,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,HUMANA,HUMANA COMMERCIAL, 2793.21,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9462,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9463,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9464,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9465,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,HUMANA,HUMANA COMMERCIAL, 1102.50,,OUTPCT LIMIT, 664.89,OTHER, 483.75, 1102.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9466,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9467,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,HUMANA,HUMANA COMMERCIAL, 3173.98,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9468,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,HUMANA,HUMANA COMMERCIAL, 3173.98,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9469,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9470,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9471,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,HUMANA,HUMANA COMMERCIAL, 3136.00,,OUTPCT LIMIT, 1665.51,OTHER, 432.18, 3136.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9472,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9473,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,HUMANA,HUMANA COMMERCIAL, 2752.67,,OUTPCT LIMIT, 1439.18,OTHER, 283.82, 2752.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9474,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9475,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,HUMANA,HUMANA COMMERCIAL, 3110.07,,OUTPCT LIMIT, 1652.58,OTHER, 432.18, 3110.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9476,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9477,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,HUMANA,HUMANA COMMERCIAL, 2940.00,,OUTPCT LIMIT, 1580.48,OTHER, 485.27, 2940.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9478,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9479,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,HUMANA,HUMANA COMMERCIAL, 3193.40,,OUTPCT LIMIT, 1712.29,OTHER, 508.57, 3193.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9480,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9481,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,HUMANA,HUMANA COMMERCIAL, 3559.63,,OUTPCT LIMIT, 1894.78,OTHER, 508.57, 3559.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9482,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9483,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,HUMANA,HUMANA COMMERCIAL, 3124.44,,OUTPCT LIMIT, 1677.93,OTHER, 508.57, 3124.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9484,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9485,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,HUMANA,HUMANA COMMERCIAL, 3881.98,,OUTPCT LIMIT, 2119.80,OTHER, 779.04, 3881.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9486,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9487,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,HUMANA,HUMANA COMMERCIAL, 4724.35,,OUTPCT LIMIT, 2539.54,OTHER, 779.04, 4724.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9488,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9489,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,HUMANA,HUMANA COMMERCIAL, 4424.64,,OUTPCT LIMIT, 2390.20,OTHER, 779.04, 4424.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9490,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9491,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9492,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9493,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9494,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,HUMANA,HUMANA COMMERCIAL, 409.23,,OUTPCT LIMIT, 236.81,OTHER, 138.19, 409.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9495,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9496,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,HUMANA,HUMANA COMMERCIAL, 323.04,,OUTPCT LIMIT, 193.87,OTHER, 138.19, 323.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9497,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9498,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,HUMANA,HUMANA COMMERCIAL, 2395.40,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9499,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,HUMANA,HUMANA COMMERCIAL, 2395.40,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9500,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9501,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9502,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,HUMANA,HUMANA COMMERCIAL, 2314.37,,OUTPCT LIMIT, 1256.10,OTHER, 432.18, 2314.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9503,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9504,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,HUMANA,HUMANA COMMERCIAL, 1563.59,,OUTPCT LIMIT, 894.65,OTHER, 485.27, 1563.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9505,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9506,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,HUMANA,HUMANA COMMERCIAL, 3272.13,,OUTPCT LIMIT, 1751.53,OTHER, 508.57, 3272.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9507,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9508,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,HUMANA,HUMANA COMMERCIAL, 4904.61,,OUTPCT LIMIT, 2629.35,OTHER, 779.04, 4904.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9509,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9510,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,HUMANA,HUMANA COMMERCIAL, 1960.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9511,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,HUMANA,HUMANA COMMERCIAL, 1960.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9512,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,HUMANA,HUMANA COMMERCIAL, 1960.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9513,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9514,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9515,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9516,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,HUMANA,HUMANA COMMERCIAL, 288.25,,OUTPCT LIMIT, 164.19,OTHER, 86.34, 288.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9517,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9518,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,HUMANA,HUMANA COMMERCIAL, 408.99,,OUTPCT LIMIT, 224.35,OTHER, 86.34, 408.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9519,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9520,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,HUMANA,HUMANA COMMERCIAL, 377.60,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9521,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,HUMANA,HUMANA COMMERCIAL, 377.60,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9522,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,HUMANA,HUMANA COMMERCIAL, 391.66,,OUTPCT LIMIT, 215.71,OTHER, 86.34, 391.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9523,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9524,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9525,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9526,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,HUMANA,HUMANA COMMERCIAL, 257.99,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9527,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,HUMANA,HUMANA COMMERCIAL, 257.99,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9528,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,HUMANA,HUMANA COMMERCIAL, 257.99,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9529,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9530,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9531,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9532,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,HUMANA,HUMANA COMMERCIAL, 311.64,,OUTPCT LIMIT, 175.84,OTHER, 86.34, 311.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9533,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,HUMANA,HUMANA COMMERCIAL, 298.03,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9534,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,HUMANA,HUMANA COMMERCIAL, 298.03,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9535,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9536,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9537,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9538,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,HUMANA,HUMANA COMMERCIAL, 405.72,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9539,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,HUMANA,HUMANA COMMERCIAL, 405.72,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9540,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,HUMANA,HUMANA COMMERCIAL, 416.34,,OUTPCT LIMIT, 240.36,OTHER, 138.19, 416.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9541,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9542,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9543,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9544,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,HUMANA,HUMANA COMMERCIAL, 399.66,,OUTPCT LIMIT, 219.70,OTHER, 86.34, 399.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9545,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,HUMANA,HUMANA COMMERCIAL, 389.13,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9546,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,HUMANA,HUMANA COMMERCIAL, 389.13,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9547,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9548,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9549,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9550,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,HUMANA,HUMANA COMMERCIAL, 373.28,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9551,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,HUMANA,HUMANA COMMERCIAL, 383.82,,OUTPCT LIMIT, 211.81,OTHER, 86.34, 383.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9552,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,HUMANA,HUMANA COMMERCIAL, 373.28,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9553,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9554,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9555,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9556,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,HUMANA,HUMANA COMMERCIAL, 420.42,,OUTPCT LIMIT, 230.04,OTHER, 86.34, 420.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9557,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,HUMANA,HUMANA COMMERCIAL, 407.29,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9558,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9559,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9560,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9561,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,HUMANA,HUMANA COMMERCIAL, 421.99,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9562,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,HUMANA,HUMANA COMMERCIAL, 421.99,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9563,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,HUMANA,HUMANA COMMERCIAL, 435.12,,OUTPCT LIMIT, 237.37,OTHER, 86.34, 435.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9564,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9565,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9566,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9567,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,HUMANA,HUMANA COMMERCIAL, 134.26,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9568,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,HUMANA,HUMANA COMMERCIAL, 186.20,,OUTPCT LIMIT, 125.68,OTHER, 81.70, 186.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9569,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,HUMANA,HUMANA COMMERCIAL, 134.26,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9570,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9571,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9572,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9573,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,HUMANA,HUMANA COMMERCIAL, 387.69,,OUTPCT LIMIT, 213.73,OTHER, 86.34, 387.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9574,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,HUMANA,HUMANA COMMERCIAL, 375.64,,OUTPCT LIMIT, 207.73,OTHER, 86.34, 375.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9575,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,HUMANA,HUMANA COMMERCIAL, 375.65,,OUTPCT LIMIT, 207.74,OTHER, 86.34, 375.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9576,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9577,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9578,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9579,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,HUMANA,HUMANA COMMERCIAL, 436.76,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9580,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,HUMANA,HUMANA COMMERCIAL, 447.30,,OUTPCT LIMIT, 243.44,OTHER, 86.34, 447.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9581,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,HUMANA,HUMANA COMMERCIAL, 436.76,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9582,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9583,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9584,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9585,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,HUMANA,HUMANA COMMERCIAL, 412.58,,OUTPCT LIMIT, 238.48,OTHER, 138.19, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9586,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,HUMANA,HUMANA COMMERCIAL, 399.45,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9587,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,HUMANA,HUMANA COMMERCIAL, 399.45,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9588,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9589,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9590,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9591,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,HUMANA,HUMANA COMMERCIAL, 400.98,,OUTPCT LIMIT, 220.36,OTHER, 86.34, 400.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9592,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,HUMANA,HUMANA COMMERCIAL, 401.10,,OUTPCT LIMIT, 220.42,OTHER, 86.34, 401.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9593,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,HUMANA,HUMANA COMMERCIAL, 411.64,,OUTPCT LIMIT, 225.67,OTHER, 86.34, 411.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9594,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9595,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9596,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9597,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,HUMANA,HUMANA COMMERCIAL, 334.08,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9598,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,HUMANA,HUMANA COMMERCIAL, 309.34,,OUTPCT LIMIT, 174.69,OTHER, 86.34, 309.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9599,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,HUMANA,HUMANA COMMERCIAL, 298.80,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9600,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,HUMANA,HUMANA COMMERCIAL, 298.80,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9601,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,HUMANA,HUMANA COMMERCIAL, 298.80,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9602,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,HUMANA,HUMANA COMMERCIAL, 298.80,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9603,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,HUMANA,HUMANA COMMERCIAL, 298.80,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9604,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,HUMANA,HUMANA COMMERCIAL, 298.80,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9605,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,HUMANA,HUMANA COMMERCIAL, 298.80,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9606,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,HUMANA,HUMANA COMMERCIAL, 298.80,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9607,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,HUMANA,HUMANA COMMERCIAL, 298.80,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9608,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,HUMANA,HUMANA COMMERCIAL, 298.80,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9609,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,HUMANA,HUMANA COMMERCIAL, 298.80,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9610,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9611,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9612,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9613,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9614,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9615,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9616,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9617,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9618,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9619,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9620,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9621,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9622,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9623,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,HUMANA,HUMANA COMMERCIAL, 1853.84,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9624,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,HUMANA,HUMANA COMMERCIAL, 1993.83,,OUTPCT LIMIT, 1061.06,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9625,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,HUMANA,HUMANA COMMERCIAL, 1993.83,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9626,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,HUMANA,HUMANA COMMERCIAL, 1993.83,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9627,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,HUMANA,HUMANA COMMERCIAL, 1993.83,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9628,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,HUMANA,HUMANA COMMERCIAL, 1993.83,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9629,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,HUMANA,HUMANA COMMERCIAL, 1993.83,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9630,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,HUMANA,HUMANA COMMERCIAL, 655.62,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9631,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,HUMANA,HUMANA COMMERCIAL, 655.62,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9632,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,HUMANA,HUMANA COMMERCIAL, 1993.83,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9633,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,HUMANA,HUMANA COMMERCIAL, 1993.83,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9634,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,HUMANA,HUMANA COMMERCIAL, 655.62,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9635,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,HUMANA,HUMANA COMMERCIAL, 1993.83,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9636,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,HUMANA,HUMANA COMMERCIAL, 1993.83,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9637,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,HUMANA,HUMANA COMMERCIAL, 1853.84,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9638,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9639,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9640,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9641,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9642,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9643,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9644,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9645,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9646,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9647,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9648,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9649,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9650,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9651,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9652,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,HUMANA,HUMANA COMMERCIAL, 2772.41,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9653,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,HUMANA,HUMANA COMMERCIAL, 2772.41,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9654,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9655,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9656,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9657,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,HUMANA,HUMANA COMMERCIAL, 1322.02,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9658,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,HUMANA,HUMANA COMMERCIAL, 1322.02,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9659,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9660,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9661,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,HUMANA,HUMANA COMMERCIAL, 1875.38,,OUTPCT LIMIT, 1055.55,OTHER, 508.57, 1875.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9662,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9663,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,HUMANA,HUMANA COMMERCIAL, 3234.25,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9664,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,HUMANA,HUMANA COMMERCIAL, 3234.25,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9665,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,HUMANA,HUMANA COMMERCIAL, 3234.25,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9666,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9667,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9668,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9669,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,HUMANA,HUMANA COMMERCIAL, 3297.38,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9670,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,HUMANA,HUMANA COMMERCIAL, 3297.38,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9671,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,HUMANA,HUMANA COMMERCIAL, 3297.38,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9672,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,HUMANA,HUMANA COMMERCIAL, 3297.38,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9673,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,HUMANA,HUMANA COMMERCIAL, 3297.38,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9674,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,HUMANA,HUMANA COMMERCIAL, 3297.38,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9675,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,HUMANA,HUMANA COMMERCIAL, 3297.38,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9676,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,HUMANA,HUMANA COMMERCIAL, 3297.38,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9677,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,HUMANA,HUMANA COMMERCIAL, 3297.38,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9678,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,HUMANA,HUMANA COMMERCIAL, 3297.38,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9679,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,HUMANA,HUMANA COMMERCIAL, 3297.38,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9680,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,HUMANA,HUMANA COMMERCIAL, 3297.38,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9681,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,HUMANA,HUMANA COMMERCIAL, 3297.38,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9682,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,HUMANA,HUMANA COMMERCIAL, 3297.38,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9683,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,HUMANA,HUMANA COMMERCIAL, 3297.38,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9684,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,HUMANA,HUMANA COMMERCIAL, 3297.38,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9685,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9686,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9687,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9688,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9689,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9690,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9691,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9692,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9693,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9694,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9695,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9696,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9697,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9698,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9699,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9700,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9701,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,HUMANA,HUMANA COMMERCIAL, 2538.45,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9702,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,HUMANA,HUMANA COMMERCIAL, 2538.45,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9703,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9704,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9705,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9706,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9707,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9708,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9709,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,HUMANA,HUMANA COMMERCIAL, 353.07,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9710,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,HUMANA,HUMANA COMMERCIAL, 353.07,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9711,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,HUMANA,HUMANA COMMERCIAL, 353.07,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9712,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9713,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9714,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9715,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,HUMANA,HUMANA COMMERCIAL, 341.01,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9716,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,HUMANA,HUMANA COMMERCIAL, 341.01,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9717,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,HUMANA,HUMANA COMMERCIAL, 341.01,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9718,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,HUMANA,HUMANA COMMERCIAL, 341.01,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9719,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,HUMANA,HUMANA COMMERCIAL, 341.01,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9720,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9721,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9722,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9723,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9724,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,HUMANA,HUMANA COMMERCIAL, 446.08,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9725,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,HUMANA,HUMANA COMMERCIAL, 354.73,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9726,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9727,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9728,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,HUMANA,HUMANA COMMERCIAL, 365.09,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9729,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,HUMANA,HUMANA COMMERCIAL, 365.09,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9730,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,HUMANA,HUMANA COMMERCIAL, 375.62,,OUTPCT LIMIT, 208.23,OTHER, 88.46, 375.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9731,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9732,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9733,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9734,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,HUMANA,HUMANA COMMERCIAL, 381.65,,OUTPCT LIMIT, 210.73,OTHER, 86.34, 381.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9735,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,HUMANA,HUMANA COMMERCIAL, 369.62,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9736,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,HUMANA,HUMANA COMMERCIAL, 369.62,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9737,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9738,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9739,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9740,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,HUMANA,HUMANA COMMERCIAL, 474.15,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9741,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,HUMANA,HUMANA COMMERCIAL, 484.69,,OUTPCT LIMIT, 274.41,OTHER, 138.19, 484.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9742,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,HUMANA,HUMANA COMMERCIAL, 474.15,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9743,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9744,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9745,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9746,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,HUMANA,HUMANA COMMERCIAL, 740.88,,OUTPCT LIMIT, 402.07,OTHER, 138.19, 740.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9747,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,HUMANA,HUMANA COMMERCIAL, 727.41,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9748,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,HUMANA,HUMANA COMMERCIAL, 727.41,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9749,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9750,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9751,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9752,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,HUMANA,HUMANA COMMERCIAL, 266.54,,OUTPCT LIMIT, 153.37,OTHER, 86.34, 266.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9753,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9754,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,HUMANA,HUMANA COMMERCIAL, 446.57,,OUTPCT LIMIT, 243.07,OTHER, 86.34, 446.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9755,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,HUMANA,HUMANA COMMERCIAL, 436.03,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9756,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,HUMANA,HUMANA COMMERCIAL, 436.03,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9757,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9758,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9759,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9760,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,HUMANA,HUMANA COMMERCIAL, 84.28,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9761,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,HUMANA,HUMANA COMMERCIAL, 84.28,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9762,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,HUMANA,HUMANA COMMERCIAL, 168.56,,OUTPCT LIMIT, 116.89,OTHER, 73.96, 168.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9763,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9764,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9765,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9766,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,HUMANA,HUMANA COMMERCIAL, 373.37,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9767,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,HUMANA,HUMANA COMMERCIAL, 373.37,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9768,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,HUMANA,HUMANA COMMERCIAL, 386.12,,OUTPCT LIMIT, 225.30,OTHER, 138.19, 386.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9769,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9770,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9771,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9772,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,HUMANA,HUMANA COMMERCIAL, 422.38,,OUTPCT LIMIT, 243.37,OTHER, 138.19, 422.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9773,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,HUMANA,HUMANA COMMERCIAL, 409.13,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9774,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,HUMANA,HUMANA COMMERCIAL, 409.13,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9775,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9776,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9777,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9778,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,HUMANA,HUMANA COMMERCIAL, 333.16,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9779,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,HUMANA,HUMANA COMMERCIAL, 333.16,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9780,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9781,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9782,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,HUMANA,HUMANA COMMERCIAL, 460.85,,OUTPCT LIMIT, 250.19,OTHER, 86.34, 460.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9783,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,HUMANA,HUMANA COMMERCIAL, 450.12,,OUTPCT LIMIT, 244.84,OTHER, 86.34, 450.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9784,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,HUMANA,HUMANA COMMERCIAL, 450.32,,OUTPCT LIMIT, 244.94,OTHER, 86.34, 450.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9785,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9786,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9787,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9788,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,HUMANA,HUMANA COMMERCIAL, 228.34,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9789,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,HUMANA,HUMANA COMMERCIAL, 228.34,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9790,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,HUMANA,HUMANA COMMERCIAL, 228.34,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9791,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9792,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9793,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9794,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,HUMANA,HUMANA COMMERCIAL, 304.91,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9795,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,HUMANA,HUMANA COMMERCIAL, 304.91,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9796,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,HUMANA,HUMANA COMMERCIAL, 304.91,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9797,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,HUMANA,HUMANA COMMERCIAL, 304.91,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9798,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,HUMANA,HUMANA COMMERCIAL, 304.91,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9799,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,HUMANA,HUMANA COMMERCIAL, 304.91,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9800,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,HUMANA,HUMANA COMMERCIAL, 304.91,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9801,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,HUMANA,HUMANA COMMERCIAL, 304.91,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9802,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 179.26,OTHER, 86.34, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9803,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,HUMANA,HUMANA COMMERCIAL, 304.91,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9804,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,HUMANA,HUMANA COMMERCIAL, 304.91,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9805,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9806,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9807,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9808,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9809,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9810,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9811,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9812,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9813,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9814,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9815,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9816,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,HUMANA,HUMANA COMMERCIAL, 2246.11,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9817,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,HUMANA,HUMANA COMMERCIAL, 2246.11,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9818,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,HUMANA,HUMANA COMMERCIAL, 2246.11,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9819,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,HUMANA,HUMANA COMMERCIAL, 2258.90,,OUTPCT LIMIT, 1193.14,OTHER, 283.82, 2258.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9820,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,HUMANA,HUMANA COMMERCIAL, 2246.11,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9821,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,HUMANA,HUMANA COMMERCIAL, 2246.11,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9822,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,HUMANA,HUMANA COMMERCIAL, 2246.11,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9823,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,HUMANA,HUMANA COMMERCIAL, 2246.11,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9824,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,HUMANA,HUMANA COMMERCIAL, 2246.11,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9825,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,HUMANA,HUMANA COMMERCIAL, 2246.11,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9826,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,HUMANA,HUMANA COMMERCIAL, 2246.11,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9827,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,HUMANA,HUMANA COMMERCIAL, 2246.11,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9828,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,HUMANA,HUMANA COMMERCIAL, 2246.11,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9829,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,HUMANA,HUMANA COMMERCIAL, 2246.11,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9830,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9831,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9832,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9833,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9834,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9835,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9836,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9837,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9838,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9839,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9840,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9841,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9842,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9843,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9844,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,HUMANA,HUMANA COMMERCIAL, 2673.44,,OUTPCT LIMIT, 1435.02,OTHER, 432.18, 2673.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9845,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,HUMANA,HUMANA COMMERCIAL, 2660.14,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9846,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,HUMANA,HUMANA COMMERCIAL, 2660.14,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9847,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9848,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9849,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9850,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,HUMANA,HUMANA COMMERCIAL, 1322.02,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9851,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,HUMANA,HUMANA COMMERCIAL, 1322.02,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9852,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,HUMANA,HUMANA COMMERCIAL, 1322.02,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9853,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9854,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9855,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9856,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,HUMANA,HUMANA COMMERCIAL, 1361.22,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9857,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,HUMANA,HUMANA COMMERCIAL, 1361.22,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9858,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9859,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9860,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,HUMANA,HUMANA COMMERCIAL, 2899.76,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9861,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,HUMANA,HUMANA COMMERCIAL, 2899.76,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9862,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,HUMANA,HUMANA COMMERCIAL, 2899.76,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9863,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,HUMANA,HUMANA COMMERCIAL, 2899.76,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9864,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,HUMANA,HUMANA COMMERCIAL, 2899.76,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9865,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,HUMANA,HUMANA COMMERCIAL, 2899.76,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9866,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9867,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9868,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9869,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9870,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9871,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9872,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,HUMANA,HUMANA COMMERCIAL, 3547.97,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9873,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,HUMANA,HUMANA COMMERCIAL, 3547.97,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9874,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9875,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9876,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,HUMANA,HUMANA COMMERCIAL, 3090.66,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9877,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,HUMANA,HUMANA COMMERCIAL, 3090.66,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9878,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,HUMANA,HUMANA COMMERCIAL, 3090.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9879,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,HUMANA,HUMANA COMMERCIAL, 3090.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9880,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,HUMANA,HUMANA COMMERCIAL, 3090.66,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9881,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,HUMANA,HUMANA COMMERCIAL, 3090.66,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9882,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,HUMANA,HUMANA COMMERCIAL, 3090.66,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9883,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,HUMANA,HUMANA COMMERCIAL, 3090.66,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9884,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,HUMANA,HUMANA COMMERCIAL, 3090.66,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9885,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,HUMANA,HUMANA COMMERCIAL, 3090.66,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9886,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9887,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9888,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9889,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9890,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9891,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9892,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9893,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9894,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9895,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9896,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,HUMANA,HUMANA COMMERCIAL, 4510.85,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9897,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,HUMANA,HUMANA COMMERCIAL, 4510.85,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9898,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,HUMANA,HUMANA COMMERCIAL, 4510.85,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9899,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,HUMANA,HUMANA COMMERCIAL, 4510.85,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9900,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,HUMANA,HUMANA COMMERCIAL, 4510.85,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9901,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9902,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9903,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9904,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9905,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9906,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,HUMANA,HUMANA COMMERCIAL, 1960.00,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9907,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,HUMANA,HUMANA COMMERCIAL, 2254.00,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9908,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,HUMANA,HUMANA COMMERCIAL, 2254.00,,OUTPCT LIMIT, 1474.10,OTHER, 989.00, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9909,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,HUMANA,HUMANA COMMERCIAL, 1793.40,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9910,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,HUMANA,HUMANA COMMERCIAL, 1793.40,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9911,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9912,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9913,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9914,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9915,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9916,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,HUMANA,HUMANA COMMERCIAL, 162.68,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9917,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,HUMANA,HUMANA COMMERCIAL, 162.68,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9918,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9919,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9920,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,HUMANA,HUMANA COMMERCIAL, 84.28,,OUTPCT LIMIT, 83.13,OTHER, 36.98, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9921,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 105.42,OTHER, 37.54, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9922,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,HUMANA,HUMANA COMMERCIAL, 581.06,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9923,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,HUMANA,HUMANA COMMERCIAL, 581.06,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9924,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9925,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9926,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,HUMANA,HUMANA COMMERCIAL, 2565.73,,OUTPCT LIMIT, 1346.03,OTHER, 283.82, 2565.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9927,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9928,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,HUMANA,HUMANA COMMERCIAL, 2892.59,,OUTPCT LIMIT, 1544.22,OTHER, 432.18, 2892.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9929,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9930,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,HUMANA,HUMANA COMMERCIAL, 3266.56,,OUTPCT LIMIT, 1743.20,OTHER, 485.27, 3266.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9931,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9932,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,HUMANA,HUMANA COMMERCIAL, 5860.43,,OUTPCT LIMIT, 3113.75,OTHER, 813.20, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9933,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,HUMANA,HUMANA COMMERCIAL, 347.90,,OUTPCT LIMIT, 473.04,OTHER, 156.77, 813.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9934,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,HUMANA,HUMANA COMMERCIAL, 3262.24,,OUTPCT LIMIT, 1743.46,OTHER, 495.38, 3262.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9935,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9936,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,HUMANA,HUMANA COMMERCIAL, 5105.03,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9937,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,HUMANA,HUMANA COMMERCIAL, 5105.03,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9938,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9939,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9940,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,HUMANA,HUMANA COMMERCIAL, 5860.43,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9941,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,HUMANA,HUMANA COMMERCIAL, 5860.43,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9942,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9943,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9944,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,HUMANA,HUMANA COMMERCIAL, 6566.21,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9945,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,HUMANA,HUMANA COMMERCIAL, 6566.21,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9946,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,HUMANA,HUMANA COMMERCIAL, 6566.21,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9947,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9948,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9949,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9950,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,HUMANA,HUMANA COMMERCIAL, 3148.01,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9951,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,HUMANA,HUMANA COMMERCIAL, 3148.01,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9952,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9953,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9954,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,HUMANA,HUMANA COMMERCIAL, 3314.55,,OUTPCT LIMIT, 1837.06,OTHER, 779.04, 3314.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9955,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9956,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,HUMANA,HUMANA COMMERCIAL, 2450.00,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9957,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,HUMANA,HUMANA COMMERCIAL, 3967.04,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9958,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9959,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9960,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9961,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,HUMANA,HUMANA COMMERCIAL, 684.04,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9962,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,HUMANA,HUMANA COMMERCIAL, 684.04,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9963,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,HUMANA,HUMANA COMMERCIAL, 684.04,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9964,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9965,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9966,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,HUMANA,HUMANA COMMERCIAL, 1076.56,,OUTPCT LIMIT, 704.06,OTHER, 472.37, 1076.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9967,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 68.02,OTHER, 37.54, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9968,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,HUMANA,HUMANA COMMERCIAL, 378.67,,OUTPCT LIMIT, 248.14,OTHER, 166.15, 378.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9969,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 230.64,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9970,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,HUMANA,HUMANA COMMERCIAL, 743.41,,OUTPCT LIMIT, 429.88,OTHER, 249.71, 743.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9971,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 132.91,OTHER, 37.54, 249.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9972,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,HUMANA,HUMANA COMMERCIAL, 2764.76,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9973,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,HUMANA,HUMANA COMMERCIAL, 2764.76,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9974,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9975,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9976,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,HUMANA,HUMANA COMMERCIAL, 343.00,,OUTPCT LIMIT, 224.32,OTHER, 150.50, 343.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9977,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9978,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,HUMANA,HUMANA COMMERCIAL, 706.08,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9979,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,HUMANA,HUMANA COMMERCIAL, 706.08,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9980,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,HUMANA,HUMANA COMMERCIAL, 706.08,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9981,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9982,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9983,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9984,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,HUMANA,HUMANA COMMERCIAL, 531.73,,OUTPCT LIMIT, 286.59,OTHER, 90.89, 531.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9985,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9986,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,HUMANA,HUMANA COMMERCIAL, 501.10,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9987,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,HUMANA,HUMANA COMMERCIAL, 501.10,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9988,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,HUMANA,HUMANA COMMERCIAL, 501.10,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9989,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,HUMANA,HUMANA COMMERCIAL, 514.50,,OUTPCT LIMIT, 288.12,OTHER, 133.37, 514.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9990,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9991,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9992,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9993,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9994,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,HUMANA,HUMANA COMMERCIAL, 942.81,,OUTPCT LIMIT, 503.49,OTHER, 141.55, 942.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9995,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9996,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,HUMANA,HUMANA COMMERCIAL, 861.03,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9997,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,HUMANA,HUMANA COMMERCIAL, 861.03,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9998,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,HUMANA,HUMANA COMMERCIAL, 861.03,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 9999,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,HUMANA,HUMANA COMMERCIAL, 861.03,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10000,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,HUMANA,HUMANA COMMERCIAL, 861.03,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10001,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10002,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10003,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10004,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10005,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10006,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,HUMANA,HUMANA COMMERCIAL, 861.03,,OUTPCT LIMIT, 468.07,OTHER, 163.97, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10007,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 200.02,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10008,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,HUMANA,HUMANA COMMERCIAL, 776.55,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10009,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,HUMANA,HUMANA COMMERCIAL, 776.55,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10010,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,HUMANA,HUMANA COMMERCIAL, 776.55,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10011,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,HUMANA,HUMANA COMMERCIAL, 776.55,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10012,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,HUMANA,HUMANA COMMERCIAL, 764.23,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10013,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10014,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10015,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10016,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10017,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10018,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,HUMANA,HUMANA COMMERCIAL, 764.23,,OUTPCT LIMIT, 414.50,OTHER, 141.55, 764.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10019,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10020,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,HUMANA,HUMANA COMMERCIAL, 367.50,,OUTPCT LIMIT, 214.87,OTHER, 133.37, 367.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10021,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 163.37,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10022,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,HUMANA,HUMANA COMMERCIAL, 752.65,,OUTPCT LIMIT, 408.73,OTHER, 141.55, 752.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10023,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10024,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,HUMANA,HUMANA COMMERCIAL, 950.97,,OUTPCT LIMIT, 507.55,OTHER, 141.55, 950.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10025,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10026,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,HUMANA,HUMANA COMMERCIAL, 1513.12,,OUTPCT LIMIT, 775.60,OTHER, 90.89, 1513.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10027,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10028,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,HUMANA,HUMANA COMMERCIAL, 519.40,,OUTPCT LIMIT, 290.56,OTHER, 133.37, 519.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10029,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10030,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,HUMANA,HUMANA COMMERCIAL, 774.81,,OUTPCT LIMIT, 419.77,OTHER, 141.55, 774.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10031,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10032,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,HUMANA,HUMANA COMMERCIAL, 878.79,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10033,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,HUMANA,HUMANA COMMERCIAL, 878.79,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10034,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,HUMANA,HUMANA COMMERCIAL, 878.79,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10035,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10036,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10037,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10038,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,HUMANA,HUMANA COMMERCIAL, 613.24,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10039,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,HUMANA,HUMANA COMMERCIAL, 592.82,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10040,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10041,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10042,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,HUMANA,HUMANA COMMERCIAL, 752.13,,OUTPCT LIMIT, 408.48,OTHER, 141.55, 752.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10043,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10044,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,HUMANA,HUMANA COMMERCIAL, 1568.00,,OUTPCT LIMIT, 813.95,OTHER, 137.10, 1568.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10045,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,HUMANA,HUMANA COMMERCIAL, 991.41,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10046,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,HUMANA,HUMANA COMMERCIAL, 991.41,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10047,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10048,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10049,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10050,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,HUMANA,HUMANA COMMERCIAL, 351.78,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10051,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,HUMANA,HUMANA COMMERCIAL, 539.00,,OUTPCT LIMIT, 300.33,OTHER, 133.37, 539.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10052,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,HUMANA,HUMANA COMMERCIAL, 351.78,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10053,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,HUMANA,HUMANA COMMERCIAL, 351.78,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10054,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,HUMANA,HUMANA COMMERCIAL, 351.78,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10055,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,HUMANA,HUMANA COMMERCIAL, 351.78,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10056,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,HUMANA,HUMANA COMMERCIAL, 351.78,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10057,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,HUMANA,HUMANA COMMERCIAL, 351.78,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10058,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,HUMANA,HUMANA COMMERCIAL, 351.78,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10059,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10060,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10061,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10062,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10063,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10064,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10065,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10066,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10067,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10068,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,HUMANA,HUMANA COMMERCIAL, 651.59,,OUTPCT LIMIT, 426.14,OTHER, 285.90, 651.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10069,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10070,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,HUMANA,HUMANA COMMERCIAL, 416.10,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10071,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,HUMANA,HUMANA COMMERCIAL, 416.10,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10072,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,HUMANA,HUMANA COMMERCIAL, 416.10,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10073,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,HUMANA,HUMANA COMMERCIAL, 349.86,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10074,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10075,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,HUMANA,HUMANA COMMERCIAL, 349.86,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10076,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,HUMANA,HUMANA COMMERCIAL, 349.86,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10077,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,HUMANA,HUMANA COMMERCIAL, 285.18,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10078,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,HUMANA,HUMANA COMMERCIAL, 285.18,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10079,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,HUMANA,HUMANA COMMERCIAL, 139.16,,OUTPCT LIMIT, 91.01,OTHER, 61.06, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10080,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,HUMANA,HUMANA COMMERCIAL, 181.30,,OUTPCT LIMIT, 78.82,OTHER, 21.15, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10081,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,HUMANA,HUMANA COMMERCIAL, 285.18,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10082,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,HUMANA,HUMANA COMMERCIAL, 285.18,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10083,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,HUMANA,HUMANA COMMERCIAL, 285.18,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10084,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,HUMANA,HUMANA COMMERCIAL, 285.18,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10085,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10086,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10087,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10088,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10089,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,HUMANA,HUMANA COMMERCIAL, 480.20,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10090,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,HUMANA,HUMANA COMMERCIAL, 400.82,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10091,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,HUMANA,HUMANA COMMERCIAL, 480.20,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10092,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10093,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10094,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,HUMANA,HUMANA COMMERCIAL, 285.18,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10095,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,HUMANA,HUMANA COMMERCIAL, 285.18,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10096,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,HUMANA,HUMANA COMMERCIAL, 285.18,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10097,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,HUMANA,HUMANA COMMERCIAL, 285.18,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10098,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,HUMANA,HUMANA COMMERCIAL, 588.00,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10099,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,HUMANA,HUMANA COMMERCIAL, 406.70,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10100,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,HUMANA,HUMANA COMMERCIAL, 406.70,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10101,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10102,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10103,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10104,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10105,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10106,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10107,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10108,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,HUMANA,HUMANA COMMERCIAL, 167.58,,OUTPCT LIMIT, 116.40,OTHER, 73.53, 167.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10109,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,HUMANA,HUMANA COMMERCIAL, 41.16,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10110,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,HUMANA,HUMANA COMMERCIAL, 720.13,,OUTPCT LIMIT, 414.07,OTHER, 232.03, 720.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10111,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,HUMANA,HUMANA COMMERCIAL, 192.08,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10112,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,HUMANA,HUMANA COMMERCIAL, 343.98,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10113,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,HUMANA,HUMANA COMMERCIAL, 41.16,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10114,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,HUMANA,HUMANA COMMERCIAL, 41.16,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10115,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,HUMANA,HUMANA COMMERCIAL, 290.08,,OUTPCT LIMIT, 154.63,OTHER, 42.36, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10116,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,HUMANA,HUMANA COMMERCIAL, 343.98,,OUTPCT LIMIT, 204.30,OTHER, 138.19, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10117,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,HUMANA,HUMANA COMMERCIAL, 41.16,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10118,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,HUMANA,HUMANA COMMERCIAL, 1251.29,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10119,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,HUMANA,HUMANA COMMERCIAL, 1251.29,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10120,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10121,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10122,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,HUMANA,HUMANA COMMERCIAL, 972.71,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10123,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,HUMANA,HUMANA COMMERCIAL, 972.71,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10124,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10125,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10126,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,HUMANA,HUMANA COMMERCIAL, 1367.99,,OUTPCT LIMIT, 757.92,OTHER, 320.35, 1367.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10127,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 230.15,OTHER, 99.36, 320.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10128,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,HUMANA,HUMANA COMMERCIAL, 1651.68,,OUTPCT LIMIT, 899.81,OTHER, 322.62, 1651.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10129,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 230.96,OTHER, 99.36, 322.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10130,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,HUMANA,HUMANA COMMERCIAL, 1930.60,,OUTPCT LIMIT, 1092.65,OTHER, 548.80, 1930.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10131,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 311.74,OTHER, 99.36, 548.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10132,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,HUMANA,HUMANA COMMERCIAL, 1531.87,,OUTPCT LIMIT, 864.03,OTHER, 423.08, 1531.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10133,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10134,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,HUMANA,HUMANA COMMERCIAL, 490.00,,OUTPCT LIMIT, 344.89,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10135,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10136,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,HUMANA,HUMANA COMMERCIAL, 1470.00,,OUTPCT LIMIT, 830.31,OTHER, 410.92, 1470.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10137,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10138,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,HUMANA,HUMANA COMMERCIAL, 2018.80,,OUTPCT LIMIT, 1103.77,OTHER, 410.92, 2018.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10139,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10140,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,HUMANA,HUMANA COMMERCIAL, 2058.00,,OUTPCT LIMIT, 1111.16,OTHER, 359.95, 2058.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10141,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10142,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,HUMANA,HUMANA COMMERCIAL, 1080.45,,OUTPCT LIMIT, 624.07,OTHER, 359.95, 1080.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10143,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10144,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,HUMANA,HUMANA COMMERCIAL, 1177.30,,OUTPCT LIMIT, 672.34,OTHER, 360.01, 1177.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10145,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10146,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,HUMANA,HUMANA COMMERCIAL, 950.60,,OUTPCT LIMIT, 559.38,OTHER, 360.01, 950.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10147,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10148,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,HUMANA,HUMANA COMMERCIAL, 2292.57,,OUTPCT LIMIT, 1228.06,OTHER, 360.01, 2292.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10149,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10150,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,HUMANA,HUMANA COMMERCIAL, 2425.02,,OUTPCT LIMIT, 1294.05,OTHER, 360.01, 2425.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10151,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10152,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,HUMANA,HUMANA COMMERCIAL, 1073.10,,OUTPCT LIMIT, 701.80,OTHER, 470.85, 1073.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10153,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 180.04,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10154,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,HUMANA,HUMANA COMMERCIAL, 1767.43,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10155,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,HUMANA,HUMANA COMMERCIAL, 1767.43,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10156,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10157,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10158,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,HUMANA,HUMANA COMMERCIAL, 4012.39,,OUTPCT LIMIT, 2267.81,OTHER, 1127.76, 4012.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10159,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10160,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,HUMANA,HUMANA COMMERCIAL, 1423.06,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10161,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,HUMANA,HUMANA COMMERCIAL, 1423.06,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10162,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10163,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10164,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,HUMANA,HUMANA COMMERCIAL, 1140.48,,OUTPCT LIMIT, 635.79,OTHER, 283.54, 1140.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10165,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 217.00,OTHER, 99.36, 283.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10166,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,HUMANA,HUMANA COMMERCIAL, 1831.45,,OUTPCT LIMIT, 984.09,OTHER, 300.36, 1831.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10167,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 223.01,OTHER, 99.36, 300.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10168,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,HUMANA,HUMANA COMMERCIAL, 1895.63,,OUTPCT LIMIT, 1050.06,OTHER, 443.12, 1895.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10169,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 274.00,OTHER, 99.36, 443.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10170,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,HUMANA,HUMANA COMMERCIAL, 1019.20,,OUTPCT LIMIT, 684.67,OTHER, 447.20, 1019.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10171,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,HUMANA,HUMANA COMMERCIAL, 220.50,,OUTPCT LIMIT, 380.97,OTHER, 99.36, 742.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10172,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,HUMANA,HUMANA COMMERCIAL, 4668.72,,OUTPCT LIMIT, 2685.69,OTHER, 1509.32, 4668.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10173,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,HUMANA,HUMANA COMMERCIAL, 392.00,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10174,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,HUMANA,HUMANA COMMERCIAL, 4835.32,,OUTPCT LIMIT, 2768.70,OTHER, 1509.32, 4835.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10175,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,HUMANA,HUMANA COMMERCIAL, 392.00,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10176,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,HUMANA,HUMANA COMMERCIAL, 59.38,,OUTPCT LIMIT, 34.30,OTHER, 19.78, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10177,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,HUMANA,HUMANA COMMERCIAL, 59.38,,OUTPCT LIMIT, 32.49,OTHER, 12.18, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10178,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,HUMANA,HUMANA COMMERCIAL, 609.56,,OUTPCT LIMIT, 398.65,OTHER, 267.46, 609.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10179,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,HUMANA,HUMANA COMMERCIAL, 137.05,,OUTPCT LIMIT, 70.69,OTHER, 10.09, 137.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10180,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,HUMANA,HUMANA COMMERCIAL, 237.90,,OUTPCT LIMIT, 122.16,OTHER, 15.20, 237.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10181,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,HUMANA,HUMANA COMMERCIAL, 186.66,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10182,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,HUMANA,HUMANA COMMERCIAL, 186.66,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10183,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,HUMANA,HUMANA COMMERCIAL, 161.70,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10184,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,HUMANA,HUMANA COMMERCIAL, 161.70,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10185,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,HUMANA,HUMANA COMMERCIAL, 280.01,,OUTPCT LIMIT, 155.85,OTHER, 68.59, 280.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10186,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,HUMANA,HUMANA COMMERCIAL, 152.89,,OUTPCT LIMIT, 78.98,OTHER, 11.76, 152.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10187,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,HUMANA,HUMANA COMMERCIAL, 128.38,,OUTPCT LIMIT, 69.30,OTHER, 22.37, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10188,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,HUMANA,HUMANA COMMERCIAL, 438.06,,OUTPCT LIMIT, 229.30,OTHER, 46.28, 438.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10189,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,HUMANA,HUMANA COMMERCIAL, 172.73,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10190,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,HUMANA,HUMANA COMMERCIAL, 164.25,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10191,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,HUMANA,HUMANA COMMERCIAL, 98.01,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10192,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,HUMANA,HUMANA COMMERCIAL, 98.01,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10193,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,HUMANA,HUMANA COMMERCIAL, 151.58,,OUTPCT LIMIT, 80.17,OTHER, 19.50, 151.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10194,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,HUMANA,HUMANA COMMERCIAL, 94.69,,OUTPCT LIMIT, 54.61,OTHER, 31.20, 94.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10195,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,HUMANA,HUMANA COMMERCIAL, 151.49,,OUTPCT LIMIT, 80.03,OTHER, 19.08, 151.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10196,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,HUMANA,HUMANA COMMERCIAL, 149.77,,OUTPCT LIMIT, 79.17,OTHER, 19.08, 149.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10197,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,HUMANA,HUMANA COMMERCIAL, 123.79,,OUTPCT LIMIT, 63.95,OTHER, 9.52, 123.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10198,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,HUMANA,HUMANA COMMERCIAL, 46.06,,OUTPCT LIMIT, 28.28,OTHER, 20.21, 46.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10199,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,HUMANA,HUMANA COMMERCIAL, 158.84,,OUTPCT LIMIT, 83.69,OTHER, 19.08, 158.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10200,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,HUMANA,HUMANA COMMERCIAL, 96.78,,OUTPCT LIMIT, 53.47,OTHER, 22.03, 96.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10201,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,HUMANA,HUMANA COMMERCIAL, 151.06,,OUTPCT LIMIT, 79.81,OTHER, 19.08, 151.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10202,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,HUMANA,HUMANA COMMERCIAL, 80.14,,OUTPCT LIMIT, 44.64,OTHER, 19.78, 80.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10203,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,HUMANA,HUMANA COMMERCIAL, 283.39,,OUTPCT LIMIT, 145.91,OTHER, 19.78, 283.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10204,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,HUMANA,HUMANA COMMERCIAL, 120.25,,OUTPCT LIMIT, 64.76,OTHER, 20.36, 120.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10205,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,HUMANA,HUMANA COMMERCIAL, 235.32,,OUTPCT LIMIT, 121.34,OTHER, 17.16, 235.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10206,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,HUMANA,HUMANA COMMERCIAL, 160.78,,OUTPCT LIMIT, 84.76,OTHER, 19.50, 160.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10207,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,HUMANA,HUMANA COMMERCIAL, 254.77,,OUTPCT LIMIT, 134.69,OTHER, 32.53, 254.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10208,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,HUMANA,HUMANA COMMERCIAL, 169.62,,OUTPCT LIMIT, 90.91,OTHER, 26.84, 169.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10209,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,HUMANA,HUMANA COMMERCIAL, 186.53,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10210,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,HUMANA,HUMANA COMMERCIAL, 24.50,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10211,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,HUMANA,HUMANA COMMERCIAL, 39.20,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10212,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,HUMANA,HUMANA COMMERCIAL, 39.20,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10213,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,HUMANA,HUMANA COMMERCIAL, 256.64,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10214,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,HUMANA,HUMANA COMMERCIAL, 289.10,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10215,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,HUMANA,HUMANA COMMERCIAL, 165.62,,OUTPCT LIMIT, 108.31,OTHER, 72.67, 165.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10216,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,HUMANA,HUMANA COMMERCIAL, 147.00,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10217,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,HUMANA,HUMANA COMMERCIAL, 74.48,,OUTPCT LIMIT, 48.71,OTHER, 32.68, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10218,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,HUMANA,HUMANA COMMERCIAL, 275.15,,OUTPCT LIMIT, 179.95,OTHER, 120.73, 275.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10219,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,HUMANA,HUMANA COMMERCIAL, 175.27,,OUTPCT LIMIT, 114.63,OTHER, 76.91, 175.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10220,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,HUMANA,HUMANA COMMERCIAL, 40.01,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10221,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,HUMANA,HUMANA COMMERCIAL, 73.50,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10222,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,HUMANA,HUMANA COMMERCIAL, 40.01,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10223,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,HUMANA,HUMANA COMMERCIAL, 40.01,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10224,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,HUMANA,HUMANA COMMERCIAL, 138.18,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10225,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,HUMANA,HUMANA COMMERCIAL, 103.77,,OUTPCT LIMIT, 67.87,OTHER, 45.53, 103.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10226,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,HUMANA,HUMANA COMMERCIAL, 155.82,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10227,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,HUMANA,HUMANA COMMERCIAL, 155.82,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10228,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,HUMANA,HUMANA COMMERCIAL, 155.82,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10229,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,HUMANA,HUMANA COMMERCIAL, 132.30,,OUTPCT LIMIT, 86.52,OTHER, 58.05, 132.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10230,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,HUMANA,HUMANA COMMERCIAL, 84.28,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10231,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,HUMANA,HUMANA COMMERCIAL, 285.18,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10232,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,HUMANA,HUMANA COMMERCIAL, 67.83,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10233,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,HUMANA,HUMANA COMMERCIAL, 67.83,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10234,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,HUMANA,HUMANA COMMERCIAL, 67.83,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10235,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,HUMANA,HUMANA COMMERCIAL, 40.46,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10236,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,HUMANA,HUMANA COMMERCIAL, 40.46,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10237,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,HUMANA,HUMANA COMMERCIAL, 40.46,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10238,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,HUMANA,HUMANA COMMERCIAL, 12.74,,OUTPCT LIMIT, 7.12,OTHER, 3.24, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10239,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,HUMANA,HUMANA COMMERCIAL, 14.70,,OUTPCT LIMIT, 8.07,OTHER, 3.12, 14.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10240,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,HUMANA,HUMANA COMMERCIAL, 62.03,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10241,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,HUMANA,HUMANA COMMERCIAL, 62.03,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10242,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,HUMANA,HUMANA COMMERCIAL, 146.02,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10243,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,HUMANA,HUMANA COMMERCIAL, 146.02,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10244,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,HUMANA,HUMANA COMMERCIAL, 241.71,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10245,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,HUMANA,HUMANA COMMERCIAL, 241.71,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10246,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,HUMANA,HUMANA COMMERCIAL, 482.16,,OUTPCT LIMIT, 262.66,OTHER, 94.12, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10247,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,HUMANA,HUMANA COMMERCIAL, 797.86,,OUTPCT LIMIT, 428.98,OTHER, 131.99, 797.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10248,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,HUMANA,HUMANA COMMERCIAL, 198.29,,OUTPCT LIMIT, 129.68,OTHER, 87.01, 198.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10249,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,HUMANA,HUMANA COMMERCIAL, 374.36,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10250,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,HUMANA,HUMANA COMMERCIAL, 374.36,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10251,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,HUMANA,HUMANA COMMERCIAL, 103.56,,OUTPCT LIMIT, 53.15,OTHER, 6.50, 103.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10252,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,HUMANA,HUMANA COMMERCIAL, 72.46,,OUTPCT LIMIT, 38.90,OTHER, 11.76, 72.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10253,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,HUMANA,HUMANA COMMERCIAL, 268.11,,OUTPCT LIMIT, 146.83,OTHER, 55.61, 268.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10254,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,HUMANA,HUMANA COMMERCIAL, 37.00,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10255,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,HUMANA,HUMANA COMMERCIAL, 37.00,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10256,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,HUMANA,HUMANA COMMERCIAL, 52.68,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10257,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,HUMANA,HUMANA COMMERCIAL, 52.68,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10258,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,HUMANA,HUMANA COMMERCIAL, 117.60,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10259,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,HUMANA,HUMANA COMMERCIAL, 117.60,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10260,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,HUMANA,HUMANA COMMERCIAL, 95.42,,OUTPCT LIMIT, 50.88,OTHER, 13.98, 95.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10261,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,HUMANA,HUMANA COMMERCIAL, 133.37,,OUTPCT LIMIT, 71.06,OTHER, 19.36, 133.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10262,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,HUMANA,HUMANA COMMERCIAL, 210.53,,OUTPCT LIMIT, 109.86,OTHER, 20.82, 210.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10263,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,HUMANA,HUMANA COMMERCIAL, 149.34,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10264,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,HUMANA,HUMANA COMMERCIAL, 149.34,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10265,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,HUMANA,HUMANA COMMERCIAL, 116.62,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10266,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,HUMANA,HUMANA COMMERCIAL, 116.62,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10267,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,HUMANA,HUMANA COMMERCIAL, 97.47,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10268,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,HUMANA,HUMANA COMMERCIAL, 97.47,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10269,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,HUMANA,HUMANA COMMERCIAL, 181.30,,OUTPCT LIMIT, 100.38,OTHER, 42.16, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10270,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,HUMANA,HUMANA COMMERCIAL, 222.55,,OUTPCT LIMIT, 121.92,OTHER, 46.34, 222.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10271,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,HUMANA,HUMANA COMMERCIAL, 86.24,,OUTPCT LIMIT, 50.20,OTHER, 30.37, 86.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10272,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,HUMANA,HUMANA COMMERCIAL, 220.38,,OUTPCT LIMIT, 116.31,OTHER, 27.31, 220.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10273,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,HUMANA,HUMANA COMMERCIAL, 93.10,,OUTPCT LIMIT, 49.78,OTHER, 14.24, 93.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10274,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,HUMANA,HUMANA COMMERCIAL, 116.19,,OUTPCT LIMIT, 63.44,OTHER, 23.30, 116.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10275,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,HUMANA,HUMANA COMMERCIAL, 69.52,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10276,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,HUMANA,HUMANA COMMERCIAL, 69.52,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10277,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,HUMANA,HUMANA COMMERCIAL, 62.92,,OUTPCT LIMIT, 33.07,OTHER, 7.22, 62.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10278,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,HUMANA,HUMANA COMMERCIAL, 35.77,,OUTPCT LIMIT, 19.33,OTHER, 6.31, 35.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10279,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,HUMANA,HUMANA COMMERCIAL, 63.87,,OUTPCT LIMIT, 33.34,OTHER, 6.38, 63.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10280,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 56.73,OTHER, 22.92, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10281,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,HUMANA,HUMANA COMMERCIAL, 228.77,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10282,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,HUMANA,HUMANA COMMERCIAL, 244.02,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10283,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,HUMANA,HUMANA COMMERCIAL, 228.77,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10284,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,HUMANA,HUMANA COMMERCIAL, 229.73,,OUTPCT LIMIT, 123.66,OTHER, 38.58, 229.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10285,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,HUMANA,HUMANA COMMERCIAL, 64.85,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10286,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,HUMANA,HUMANA COMMERCIAL, 64.85,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10287,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,HUMANA,HUMANA COMMERCIAL, 64.85,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10288,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,HUMANA,HUMANA COMMERCIAL, 129.55,,OUTPCT LIMIT, 69.24,OTHER, 19.70, 129.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10289,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,HUMANA,HUMANA COMMERCIAL, 96.13,,OUTPCT LIMIT, 49.97,OTHER, 8.69, 96.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10290,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,HUMANA,HUMANA COMMERCIAL, 80.36,,OUTPCT LIMIT, 44.47,OTHER, 18.58, 80.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10291,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,HUMANA,HUMANA COMMERCIAL, 122.26,,OUTPCT LIMIT, 65.14,OTHER, 17.74, 122.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10292,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,HUMANA,HUMANA COMMERCIAL, 162.05,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10293,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,HUMANA,HUMANA COMMERCIAL, 162.05,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10294,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,HUMANA,HUMANA COMMERCIAL, 106.82,,OUTPCT LIMIT, 59.01,OTHER, 24.29, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10295,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,HUMANA,HUMANA COMMERCIAL, 238.24,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10296,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,HUMANA,HUMANA COMMERCIAL, 240.51,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10297,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,HUMANA,HUMANA COMMERCIAL, 105.91,,OUTPCT LIMIT, 56.46,OTHER, 15.47, 105.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10298,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,HUMANA,HUMANA COMMERCIAL, 23.52,,OUTPCT LIMIT, 13.69,OTHER, 8.28, 23.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10299,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,HUMANA,HUMANA COMMERCIAL, 139.40,,OUTPCT LIMIT, 73.71,OTHER, 17.87, 139.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10300,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,HUMANA,HUMANA COMMERCIAL, 164.57,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10301,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,HUMANA,HUMANA COMMERCIAL, 164.57,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10302,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,HUMANA,HUMANA COMMERCIAL, 121.86,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10303,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,HUMANA,HUMANA COMMERCIAL, 121.86,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10304,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,HUMANA,HUMANA COMMERCIAL, 365.11,,OUTPCT LIMIT, 190.19,OTHER, 34.69, 365.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10305,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,HUMANA,HUMANA COMMERCIAL, 412.93,,OUTPCT LIMIT, 214.01,OTHER, 34.69, 412.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10306,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,HUMANA,HUMANA COMMERCIAL, 90.83,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10307,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,HUMANA,HUMANA COMMERCIAL, 90.83,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10308,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,HUMANA,HUMANA COMMERCIAL, 74.48,,OUTPCT LIMIT, 41.70,OTHER, 19.28, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10309,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,HUMANA,HUMANA COMMERCIAL, 111.92,,OUTPCT LIMIT, 59.73,OTHER, 16.63, 111.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10310,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,HUMANA,HUMANA COMMERCIAL, 59.95,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10311,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,HUMANA,HUMANA COMMERCIAL, 59.95,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10312,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,HUMANA,HUMANA COMMERCIAL, 59.95,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10313,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,HUMANA,HUMANA COMMERCIAL, 74.93,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10314,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,HUMANA,HUMANA COMMERCIAL, 74.93,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10315,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,HUMANA,HUMANA COMMERCIAL, 181.07,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10316,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,HUMANA,HUMANA COMMERCIAL, 181.07,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10317,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,HUMANA,HUMANA COMMERCIAL, 82.32,,OUTPCT LIMIT, 45.06,OTHER, 16.97, 82.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10318,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,HUMANA,HUMANA COMMERCIAL, 148.50,,OUTPCT LIMIT, 76.21,OTHER, 9.31, 148.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10319,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,HUMANA,HUMANA COMMERCIAL, 134.58,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10320,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,HUMANA,HUMANA COMMERCIAL, 134.58,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10321,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,HUMANA,HUMANA COMMERCIAL, 138.50,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10322,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,HUMANA,HUMANA COMMERCIAL, 138.50,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10323,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,HUMANA,HUMANA COMMERCIAL, 238.34,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10324,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,HUMANA,HUMANA COMMERCIAL, 238.34,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10325,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,HUMANA,HUMANA COMMERCIAL, 175.46,,OUTPCT LIMIT, 93.87,OTHER, 27.06, 175.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10326,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,HUMANA,HUMANA COMMERCIAL, 252.68,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10327,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,HUMANA,HUMANA COMMERCIAL, 252.68,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10328,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,HUMANA,HUMANA COMMERCIAL, 146.02,,OUTPCT LIMIT, 83.83,OTHER, 46.51, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10329,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,HUMANA,HUMANA COMMERCIAL, 131.32,,OUTPCT LIMIT, 73.72,OTHER, 34.82, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10330,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,HUMANA,HUMANA COMMERCIAL, 134.26,,OUTPCT LIMIT, 75.45,OTHER, 35.93, 134.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10331,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,HUMANA,HUMANA COMMERCIAL, 228.10,,OUTPCT LIMIT, 121.64,OTHER, 33.53, 228.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10332,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,HUMANA,HUMANA COMMERCIAL, 135.30,,OUTPCT LIMIT, 69.17,OTHER, 7.34, 135.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10333,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,HUMANA,HUMANA COMMERCIAL, 238.64,,OUTPCT LIMIT, 124.67,OTHER, 24.19, 238.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10334,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,HUMANA,HUMANA COMMERCIAL, 144.06,,OUTPCT LIMIT, 76.46,OTHER, 19.63, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10335,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,HUMANA,HUMANA COMMERCIAL, 133.34,,OUTPCT LIMIT, 71.48,OTHER, 21.17, 133.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10336,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,HUMANA,HUMANA COMMERCIAL, 415.28,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10337,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,HUMANA,HUMANA COMMERCIAL, 151.91,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10338,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,HUMANA,HUMANA COMMERCIAL, 103.64,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10339,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,HUMANA,HUMANA COMMERCIAL, 103.64,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10340,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,HUMANA,HUMANA COMMERCIAL, 103.64,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10341,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,HUMANA,HUMANA COMMERCIAL, 119.04,,OUTPCT LIMIT, 64.96,OTHER, 23.70, 119.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10342,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,HUMANA,HUMANA COMMERCIAL, 64.68,,OUTPCT LIMIT, 34.98,OTHER, 11.54, 64.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10343,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,HUMANA,HUMANA COMMERCIAL, 390.51,,OUTPCT LIMIT, 203.52,OTHER, 37.54, 390.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10344,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,HUMANA,HUMANA COMMERCIAL, 111.72,,OUTPCT LIMIT, 61.71,OTHER, 25.39, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10345,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,HUMANA,HUMANA COMMERCIAL, 48.76,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10346,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,HUMANA,HUMANA COMMERCIAL, 48.76,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10347,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,HUMANA,HUMANA COMMERCIAL, 48.76,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10348,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,HUMANA,HUMANA COMMERCIAL, 54.13,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10349,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,HUMANA,HUMANA COMMERCIAL, 54.13,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10350,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,HUMANA,HUMANA COMMERCIAL, 54.13,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10351,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,HUMANA,HUMANA COMMERCIAL, 25.68,,OUTPCT LIMIT, 14.14,OTHER, 5.66, 25.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10352,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,HUMANA,HUMANA COMMERCIAL, 126.10,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10353,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,HUMANA,HUMANA COMMERCIAL, 126.10,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10354,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,HUMANA,HUMANA COMMERCIAL, 109.55,,OUTPCT LIMIT, 57.91,OTHER, 13.97, 109.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10355,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,HUMANA,HUMANA COMMERCIAL, 70.39,,OUTPCT LIMIT, 37.55,OTHER, 10.37, 70.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10356,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,HUMANA,HUMANA COMMERCIAL, 177.33,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10357,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,HUMANA,HUMANA COMMERCIAL, 177.33,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10358,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,HUMANA,HUMANA COMMERCIAL, 176.95,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10359,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,HUMANA,HUMANA COMMERCIAL, 176.95,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10360,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,HUMANA,HUMANA COMMERCIAL, 125.90,,OUTPCT LIMIT, 67.05,OTHER, 18.12, 125.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10361,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,HUMANA,HUMANA COMMERCIAL, 135.24,,OUTPCT LIMIT, 74.92,OTHER, 31.62, 135.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10362,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,HUMANA,HUMANA COMMERCIAL, 90.26,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10363,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,HUMANA,HUMANA COMMERCIAL, 90.26,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10364,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,HUMANA,HUMANA COMMERCIAL, 90.26,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10365,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,HUMANA,HUMANA COMMERCIAL, 188.02,,OUTPCT LIMIT, 99.83,OTHER, 25.80, 188.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10366,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,HUMANA,HUMANA COMMERCIAL, 294.98,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10367,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,HUMANA,HUMANA COMMERCIAL, 260.07,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10368,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,HUMANA,HUMANA COMMERCIAL, 260.07,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10369,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,HUMANA,HUMANA COMMERCIAL, 260.07,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10370,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,HUMANA,HUMANA COMMERCIAL, 260.07,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10371,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,HUMANA,HUMANA COMMERCIAL, 260.07,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10372,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,HUMANA,HUMANA COMMERCIAL, 290.68,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10373,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,HUMANA,HUMANA COMMERCIAL, 175.48,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10374,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,HUMANA,HUMANA COMMERCIAL, 270.57,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10375,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,HUMANA,HUMANA COMMERCIAL, 42.14,,OUTPCT LIMIT, 25.93,OTHER, 18.49, 42.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10376,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,HUMANA,HUMANA COMMERCIAL, 130.69,,OUTPCT LIMIT, 69.04,OTHER, 16.46, 130.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10377,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,HUMANA,HUMANA COMMERCIAL, 83.61,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10378,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,HUMANA,HUMANA COMMERCIAL, 83.61,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10379,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,HUMANA,HUMANA COMMERCIAL, 83.61,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10380,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,HUMANA,HUMANA COMMERCIAL, 102.31,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10381,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,HUMANA,HUMANA COMMERCIAL, 102.31,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10382,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,HUMANA,HUMANA COMMERCIAL, 102.31,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10383,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,HUMANA,HUMANA COMMERCIAL, 102.31,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10384,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,HUMANA,HUMANA COMMERCIAL, 132.59,,OUTPCT LIMIT, 70.04,OTHER, 16.66, 132.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10385,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,HUMANA,HUMANA COMMERCIAL, 84.73,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10386,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,HUMANA,HUMANA COMMERCIAL, 111.64,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10387,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,HUMANA,HUMANA COMMERCIAL, 162.68,,OUTPCT LIMIT, 85.45,OTHER, 18.42, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10388,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,HUMANA,HUMANA COMMERCIAL, 124.46,,OUTPCT LIMIT, 68.77,OTHER, 28.37, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10389,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,HUMANA,HUMANA COMMERCIAL, 101.58,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10390,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,HUMANA,HUMANA COMMERCIAL, 101.58,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10391,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,HUMANA,HUMANA COMMERCIAL, 116.63,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10392,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,HUMANA,HUMANA COMMERCIAL, 116.63,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10393,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,HUMANA,HUMANA COMMERCIAL, 267.27,,OUTPCT LIMIT, 149.05,OTHER, 66.68, 267.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10394,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,HUMANA,HUMANA COMMERCIAL, 63.70,,OUTPCT LIMIT, 43.46,OTHER, 27.95, 63.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10395,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,HUMANA,HUMANA COMMERCIAL, 79.09,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10396,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,HUMANA,HUMANA COMMERCIAL, 79.09,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10397,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,HUMANA,HUMANA COMMERCIAL, 76.95,,OUTPCT LIMIT, 40.64,OTHER, 9.65, 76.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10398,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,HUMANA,HUMANA COMMERCIAL, 392.89,,OUTPCT LIMIT, 204.04,OTHER, 34.72, 392.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10399,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,HUMANA,HUMANA COMMERCIAL, 104.19,,OUTPCT LIMIT, 57.49,OTHER, 23.41, 104.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10400,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,HUMANA,HUMANA COMMERCIAL, 308.57,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10401,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,HUMANA,HUMANA COMMERCIAL, 308.57,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10402,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,HUMANA,HUMANA COMMERCIAL, 163.34,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10403,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,HUMANA,HUMANA COMMERCIAL, 119.09,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10404,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,HUMANA,HUMANA COMMERCIAL, 214.62,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10405,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,HUMANA,HUMANA COMMERCIAL, 214.62,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10406,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,HUMANA,HUMANA COMMERCIAL, 208.08,,OUTPCT LIMIT, 110.95,OTHER, 30.54, 208.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10407,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,HUMANA,HUMANA COMMERCIAL, 104.16,,OUTPCT LIMIT, 54.17,OTHER, 9.52, 104.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10408,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,HUMANA,HUMANA COMMERCIAL, 84.52,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10409,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,HUMANA,HUMANA COMMERCIAL, 84.52,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10410,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,HUMANA,HUMANA COMMERCIAL, 162.94,,OUTPCT LIMIT, 86.15,OTHER, 20.81, 162.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10411,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,HUMANA,HUMANA COMMERCIAL, 266.61,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10412,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,HUMANA,HUMANA COMMERCIAL, 266.61,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10413,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,HUMANA,HUMANA COMMERCIAL, 74.48,,OUTPCT LIMIT, 43.75,OTHER, 27.89, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10414,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,HUMANA,HUMANA COMMERCIAL, 361.00,,OUTPCT LIMIT, 186.61,OTHER, 28.27, 361.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10415,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,HUMANA,HUMANA COMMERCIAL, 84.28,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10416,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,HUMANA,HUMANA COMMERCIAL, 92.71,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10417,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,HUMANA,HUMANA COMMERCIAL, 67.37,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10418,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,HUMANA,HUMANA COMMERCIAL, 67.37,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10419,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,HUMANA,HUMANA COMMERCIAL, 54.66,,OUTPCT LIMIT, 28.87,OTHER, 6.85, 54.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10420,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,HUMANA,HUMANA COMMERCIAL, 24.50,,OUTPCT LIMIT, 13.83,OTHER, 6.82, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10421,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,HUMANA,HUMANA COMMERCIAL, 81.40,,OUTPCT LIMIT, 45.56,OTHER, 21.01, 81.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10422,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,HUMANA,HUMANA COMMERCIAL, 171.74,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10423,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,HUMANA,HUMANA COMMERCIAL, 171.74,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10424,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,HUMANA,HUMANA COMMERCIAL, 187.57,,OUTPCT LIMIT, 102.79,OTHER, 39.19, 187.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10425,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,HUMANA,HUMANA COMMERCIAL, 181.67,,OUTPCT LIMIT, 97.17,OTHER, 27.91, 181.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10426,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,HUMANA,HUMANA COMMERCIAL, 162.00,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10427,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,HUMANA,HUMANA COMMERCIAL, 174.77,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10428,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,HUMANA,HUMANA COMMERCIAL, 174.77,,OUTPCT LIMIT, 93.39,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10429,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,HUMANA,HUMANA COMMERCIAL, 46.96,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10430,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,HUMANA,HUMANA COMMERCIAL, 46.96,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10431,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,HUMANA,HUMANA COMMERCIAL, 113.55,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10432,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,HUMANA,HUMANA COMMERCIAL, 113.55,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10433,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,HUMANA,HUMANA COMMERCIAL, 113.55,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10434,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,HUMANA,HUMANA COMMERCIAL, 80.16,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10435,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,HUMANA,HUMANA COMMERCIAL, 80.16,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10436,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,HUMANA,HUMANA COMMERCIAL, 83.71,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10437,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,HUMANA,HUMANA COMMERCIAL, 390.13,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10438,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,HUMANA,HUMANA COMMERCIAL, 173.32,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10439,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,HUMANA,HUMANA COMMERCIAL, 149.47,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10440,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,HUMANA,HUMANA COMMERCIAL, 394.32,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10441,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,HUMANA,HUMANA COMMERCIAL, 255.27,,OUTPCT LIMIT, 136.35,OTHER, 38.44, 255.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10442,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,HUMANA,HUMANA COMMERCIAL, 187.92,,OUTPCT LIMIT, 103.27,OTHER, 40.46, 187.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10443,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,HUMANA,HUMANA COMMERCIAL, 139.16,,OUTPCT LIMIT, 76.88,OTHER, 31.67, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10444,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,HUMANA,HUMANA COMMERCIAL, 344.96,,OUTPCT LIMIT, 178.83,OTHER, 29.15, 344.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10445,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,HUMANA,HUMANA COMMERCIAL, 162.51,,OUTPCT LIMIT, 88.43,OTHER, 31.30, 162.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10446,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,HUMANA,HUMANA COMMERCIAL, 56.94,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10447,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,HUMANA,HUMANA COMMERCIAL, 56.94,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10448,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,HUMANA,HUMANA COMMERCIAL, 88.56,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10449,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,HUMANA,HUMANA COMMERCIAL, 88.56,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10450,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,HUMANA,HUMANA COMMERCIAL, 18.18,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10451,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,HUMANA,HUMANA COMMERCIAL, 348.07,,OUTPCT LIMIT, 180.72,OTHER, 30.61, 348.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10452,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,HUMANA,HUMANA COMMERCIAL, 602.43,,OUTPCT LIMIT, 302.95,OTHER, 11.66, 602.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10453,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,HUMANA,HUMANA COMMERCIAL, 146.83,,OUTPCT LIMIT, 81.90,OTHER, 36.67, 146.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10454,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,HUMANA,HUMANA COMMERCIAL, 229.34,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10455,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,HUMANA,HUMANA COMMERCIAL, 229.34,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10456,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,HUMANA,HUMANA COMMERCIAL, 229.34,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10457,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,HUMANA,HUMANA COMMERCIAL, 229.34,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10458,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,HUMANA,HUMANA COMMERCIAL, 159.58,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10459,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,HUMANA,HUMANA COMMERCIAL, 159.58,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10460,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,HUMANA,HUMANA COMMERCIAL, 204.40,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10461,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,HUMANA,HUMANA COMMERCIAL, 204.40,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10462,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,HUMANA,HUMANA COMMERCIAL, 102.18,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10463,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,HUMANA,HUMANA COMMERCIAL, 102.18,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10464,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,HUMANA,HUMANA COMMERCIAL, 146.22,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10465,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,HUMANA,HUMANA COMMERCIAL, 146.22,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10466,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,HUMANA,HUMANA COMMERCIAL, 146.22,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10467,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,HUMANA,HUMANA COMMERCIAL, 94.08,,OUTPCT LIMIT, 51.95,OTHER, 21.29, 94.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10468,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,HUMANA,HUMANA COMMERCIAL, 136.01,,OUTPCT LIMIT, 73.53,OTHER, 24.19, 136.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10469,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,HUMANA,HUMANA COMMERCIAL, 274.40,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10470,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,HUMANA,HUMANA COMMERCIAL, 274.40,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10471,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,HUMANA,HUMANA COMMERCIAL, 90.16,,OUTPCT LIMIT, 49.79,OTHER, 20.42, 90.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10472,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,HUMANA,HUMANA COMMERCIAL, 73.33,,OUTPCT LIMIT, 38.32,OTHER, 7.46, 73.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10473,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,HUMANA,HUMANA COMMERCIAL, 68.58,,OUTPCT LIMIT, 35.99,OTHER, 7.63, 68.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10474,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,HUMANA,HUMANA COMMERCIAL, 108.64,,OUTPCT LIMIT, 58.51,OTHER, 18.37, 108.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10475,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,HUMANA,HUMANA COMMERCIAL, 74.59,,OUTPCT LIMIT, 39.13,OTHER, 8.27, 74.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10476,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,HUMANA,HUMANA COMMERCIAL, 149.61,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10477,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,HUMANA,HUMANA COMMERCIAL, 149.61,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10478,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,HUMANA,HUMANA COMMERCIAL, 146.69,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10479,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,HUMANA,HUMANA COMMERCIAL, 146.69,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10480,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,HUMANA,HUMANA COMMERCIAL, 243.80,,OUTPCT LIMIT, 126.89,OTHER, 22.69, 243.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10481,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,HUMANA,HUMANA COMMERCIAL, 157.98,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10482,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,HUMANA,HUMANA COMMERCIAL, 157.98,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10483,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,HUMANA,HUMANA COMMERCIAL, 75.80,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10484,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,HUMANA,HUMANA COMMERCIAL, 75.80,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10485,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,HUMANA,HUMANA COMMERCIAL, 75.80,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10486,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,HUMANA,HUMANA COMMERCIAL, 41.53,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10487,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,HUMANA,HUMANA COMMERCIAL, 41.53,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10488,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,HUMANA,HUMANA COMMERCIAL, 60.86,,OUTPCT LIMIT, 31.87,OTHER, 6.50, 60.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10489,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,HUMANA,HUMANA COMMERCIAL, 74.97,,OUTPCT LIMIT, 39.10,OTHER, 7.32, 74.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10490,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,HUMANA,HUMANA COMMERCIAL, 145.21,,OUTPCT LIMIT, 76.33,OTHER, 16.72, 145.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10491,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,HUMANA,HUMANA COMMERCIAL, 198.70,,OUTPCT LIMIT, 103.71,OTHER, 19.75, 198.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10492,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,HUMANA,HUMANA COMMERCIAL, 105.92,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10493,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,HUMANA,HUMANA COMMERCIAL, 105.92,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10494,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,HUMANA,HUMANA COMMERCIAL, 105.92,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10495,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,HUMANA,HUMANA COMMERCIAL, 157.49,,OUTPCT LIMIT, 85.61,OTHER, 29.96, 157.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10496,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,HUMANA,HUMANA COMMERCIAL, 184.39,,OUTPCT LIMIT, 97.04,OTHER, 21.67, 184.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10497,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,HUMANA,HUMANA COMMERCIAL, 82.74,,OUTPCT LIMIT, 42.88,OTHER, 6.94, 82.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10498,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,HUMANA,HUMANA COMMERCIAL, 85.29,,OUTPCT LIMIT, 43.80,OTHER, 5.47, 85.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10499,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,HUMANA,HUMANA COMMERCIAL, 34.19,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10500,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,HUMANA,HUMANA COMMERCIAL, 34.19,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10501,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,HUMANA,HUMANA COMMERCIAL, 41.43,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10502,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,HUMANA,HUMANA COMMERCIAL, 41.43,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10503,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10504,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,HUMANA,HUMANA COMMERCIAL, 84.19,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10505,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,HUMANA,HUMANA COMMERCIAL, 85.28,,OUTPCT LIMIT, 44.71,OTHER, 9.31, 85.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10506,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,HUMANA,HUMANA COMMERCIAL, 72.82,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10507,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,HUMANA,HUMANA COMMERCIAL, 72.82,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10508,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,HUMANA,HUMANA COMMERCIAL, 38.22,,OUTPCT LIMIT, 19.92,OTHER, 3.66, 38.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10509,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,HUMANA,HUMANA COMMERCIAL, 62.40,,OUTPCT LIMIT, 32.63,OTHER, 6.46, 62.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10510,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,HUMANA,HUMANA COMMERCIAL, 181.90,,OUTPCT LIMIT, 96.77,OTHER, 25.78, 181.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10511,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,HUMANA,HUMANA COMMERCIAL, 243.72,,OUTPCT LIMIT, 129.31,OTHER, 33.04, 243.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10512,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,HUMANA,HUMANA COMMERCIAL, 253.82,,OUTPCT LIMIT, 130.54,OTHER, 17.06, 253.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10513,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,HUMANA,HUMANA COMMERCIAL, 187.84,,OUTPCT LIMIT, 98.34,OTHER, 19.93, 187.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10514,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,HUMANA,HUMANA COMMERCIAL, 168.07,,OUTPCT LIMIT, 89.00,OTHER, 22.06, 168.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10515,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,HUMANA,HUMANA COMMERCIAL, 190.12,,OUTPCT LIMIT, 98.22,OTHER, 14.66, 190.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10516,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,HUMANA,HUMANA COMMERCIAL, 102.96,,OUTPCT LIMIT, 54.63,OTHER, 13.99, 102.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10517,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,HUMANA,HUMANA COMMERCIAL, 128.38,,OUTPCT LIMIT, 70.40,OTHER, 27.00, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10518,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,HUMANA,HUMANA COMMERCIAL, 57.09,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10519,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,HUMANA,HUMANA COMMERCIAL, 56.72,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10520,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,HUMANA,HUMANA COMMERCIAL, 57.09,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10521,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,HUMANA,HUMANA COMMERCIAL, 25.48,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10522,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,HUMANA,HUMANA COMMERCIAL, 25.48,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10523,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,HUMANA,HUMANA COMMERCIAL, 25.48,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10524,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,HUMANA,HUMANA COMMERCIAL, 25.48,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10525,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,HUMANA,HUMANA COMMERCIAL, 80.56,,OUTPCT LIMIT, 41.60,OTHER, 6.14, 80.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10526,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,HUMANA,HUMANA COMMERCIAL, 50.96,,OUTPCT LIMIT, 26.32,OTHER, 3.89, 50.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10527,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,HUMANA,HUMANA COMMERCIAL, 69.16,,OUTPCT LIMIT, 36.35,OTHER, 7.93, 69.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10528,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,HUMANA,HUMANA COMMERCIAL, 166.60,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10529,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,HUMANA,HUMANA COMMERCIAL, 73.38,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10530,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,HUMANA,HUMANA COMMERCIAL, 148.49,,OUTPCT LIMIT, 76.67,OTHER, 11.26, 148.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10531,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,HUMANA,HUMANA COMMERCIAL, 1164.58,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10532,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,HUMANA,HUMANA COMMERCIAL, 316.54,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10533,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10534,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10535,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10536,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10537,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10538,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10539,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10540,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10541,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10542,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10543,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10544,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10545,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10546,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10547,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10548,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10549,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10550,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10551,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10552,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10553,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10554,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10555,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10556,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10557,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10558,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10559,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10560,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10561,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10562,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10563,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10564,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10565,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10566,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10567,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10568,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10569,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,HUMANA,HUMANA COMMERCIAL, 60.41,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10570,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10571,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10572,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10573,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10574,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,HUMANA,HUMANA COMMERCIAL, 31.46,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10575,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10576,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10577,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10578,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10579,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10580,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10581,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10582,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10583,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10584,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10585,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10586,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10587,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10588,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10589,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10590,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10591,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10592,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,HUMANA,HUMANA COMMERCIAL, 65.35,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10593,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,HUMANA,HUMANA COMMERCIAL, 367.26,,OUTPCT LIMIT, 189.29,OTHER, 26.45, 367.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10594,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,HUMANA,HUMANA COMMERCIAL, 224.23,,OUTPCT LIMIT, 115.17,OTHER, 14.46, 224.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10595,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,HUMANA,HUMANA COMMERCIAL, 130.63,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10596,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,HUMANA,HUMANA COMMERCIAL, 220.77,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10597,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,HUMANA,HUMANA COMMERCIAL, 90.48,,OUTPCT LIMIT, 48.91,OTHER, 16.07, 90.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10598,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,HUMANA,HUMANA COMMERCIAL, 85.75,,OUTPCT LIMIT, 45.23,OTHER, 10.51, 85.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10599,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,HUMANA,HUMANA COMMERCIAL, 30.71,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10600,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,HUMANA,HUMANA COMMERCIAL, 30.71,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10601,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,HUMANA,HUMANA COMMERCIAL, 110.01,,OUTPCT LIMIT, 59.25,OTHER, 18.65, 110.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10602,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,HUMANA,HUMANA COMMERCIAL, 171.10,,OUTPCT LIMIT, 93.98,OTHER, 36.65, 171.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10603,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,HUMANA,HUMANA COMMERCIAL, 258.18,,OUTPCT LIMIT, 137.37,OTHER, 36.65, 258.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10604,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,HUMANA,HUMANA COMMERCIAL, 146.41,,OUTPCT LIMIT, 78.46,OTHER, 23.14, 146.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10605,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,HUMANA,HUMANA COMMERCIAL, 127.65,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10606,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,HUMANA,HUMANA COMMERCIAL, 127.33,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10607,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,HUMANA,HUMANA COMMERCIAL, 141.93,,OUTPCT LIMIT, 77.69,OTHER, 29.26, 141.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10608,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,HUMANA,HUMANA COMMERCIAL, 117.89,,OUTPCT LIMIT, 63.19,OTHER, 18.65, 117.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10609,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,HUMANA,HUMANA COMMERCIAL, 117.73,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10610,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,HUMANA,HUMANA COMMERCIAL, 127.80,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10611,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,HUMANA,HUMANA COMMERCIAL, 138.62,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10612,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,HUMANA,HUMANA COMMERCIAL, 138.62,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10613,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,HUMANA,HUMANA COMMERCIAL, 138.62,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10614,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,HUMANA,HUMANA COMMERCIAL, 138.62,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10615,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,HUMANA,HUMANA COMMERCIAL, 138.79,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10616,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,HUMANA,HUMANA COMMERCIAL, 138.62,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10617,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,HUMANA,HUMANA COMMERCIAL, 118.43,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10618,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,HUMANA,HUMANA COMMERCIAL, 110.41,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10619,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,HUMANA,HUMANA COMMERCIAL, 155.82,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10620,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,HUMANA,HUMANA COMMERCIAL, 238.31,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10621,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,HUMANA,HUMANA COMMERCIAL, 230.06,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10622,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,HUMANA,HUMANA COMMERCIAL, 24.50,,OUTPCT LIMIT, 15.65,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10623,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,HUMANA,HUMANA COMMERCIAL, 146.06,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10624,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,HUMANA,HUMANA COMMERCIAL, 150.18,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10625,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,HUMANA,HUMANA COMMERCIAL, 156.52,,OUTPCT LIMIT, 85.12,OTHER, 29.96, 156.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10626,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,HUMANA,HUMANA COMMERCIAL, 193.30,,OUTPCT LIMIT, 103.45,OTHER, 29.96, 193.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10627,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,HUMANA,HUMANA COMMERCIAL, 132.59,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10628,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,HUMANA,HUMANA COMMERCIAL, 345.45,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10629,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,HUMANA,HUMANA COMMERCIAL, 97.86,,OUTPCT LIMIT, 50.54,OTHER, 7.46, 97.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10630,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,HUMANA,HUMANA COMMERCIAL, 162.98,,OUTPCT LIMIT, 88.87,OTHER, 32.17, 162.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10631,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,HUMANA,HUMANA COMMERCIAL, 118.58,,OUTPCT LIMIT, 66.43,OTHER, 30.83, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10632,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,HUMANA,HUMANA COMMERCIAL, 104.87,,OUTPCT LIMIT, 57.43,OTHER, 21.72, 104.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10633,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,HUMANA,HUMANA COMMERCIAL, 515.73,,OUTPCT LIMIT, 265.06,OTHER, 33.95, 515.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10634,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,HUMANA,HUMANA COMMERCIAL, 144.06,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10635,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,HUMANA,HUMANA COMMERCIAL, 144.06,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10636,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,HUMANA,HUMANA COMMERCIAL, 198.45,,OUTPCT LIMIT, 111.82,OTHER, 54.34, 198.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10637,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,HUMANA,HUMANA COMMERCIAL, 321.34,,OUTPCT LIMIT, 176.22,OTHER, 67.64, 321.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10638,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,HUMANA,HUMANA COMMERCIAL, 158.27,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10639,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,HUMANA,HUMANA COMMERCIAL, 158.27,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10640,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,HUMANA,HUMANA COMMERCIAL, 131.32,,OUTPCT LIMIT, 68.73,OTHER, 13.84, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10641,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,HUMANA,HUMANA COMMERCIAL, 159.86,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10642,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,HUMANA,HUMANA COMMERCIAL, 205.80,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10643,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,HUMANA,HUMANA COMMERCIAL, 131.32,,OUTPCT LIMIT, 70.10,OTHER, 19.60, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10644,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,HUMANA,HUMANA COMMERCIAL, 90.14,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10645,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,HUMANA,HUMANA COMMERCIAL, 90.14,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10646,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,HUMANA,HUMANA COMMERCIAL, 342.02,,OUTPCT LIMIT, 191.67,OTHER, 89.24, 342.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10647,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,HUMANA,HUMANA COMMERCIAL, 18.33,,OUTPCT LIMIT, 12.31,OTHER, 8.04, 18.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10648,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,HUMANA,HUMANA COMMERCIAL, 34.21,,OUTPCT LIMIT, 18.56,OTHER, 6.34, 34.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10649,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,HUMANA,HUMANA COMMERCIAL, 62.31,,OUTPCT LIMIT, 36.21,OTHER, 21.67, 62.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10650,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,HUMANA,HUMANA COMMERCIAL, 103.88,,OUTPCT LIMIT, 55.25,OTHER, 14.66, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10651,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,HUMANA,HUMANA COMMERCIAL, 71.66,,OUTPCT LIMIT, 40.13,OTHER, 18.58, 71.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10652,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,HUMANA,HUMANA COMMERCIAL, 124.46,,OUTPCT LIMIT, 66.54,OTHER, 19.00, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10653,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,HUMANA,HUMANA COMMERCIAL, 165.65,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10654,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,HUMANA,HUMANA COMMERCIAL, 165.65,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10655,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,HUMANA,HUMANA COMMERCIAL, 165.65,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10656,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,HUMANA,HUMANA COMMERCIAL, 45.41,,OUTPCT LIMIT, 26.75,OTHER, 17.29, 45.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10657,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,HUMANA,HUMANA COMMERCIAL, 94.99,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10658,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,HUMANA,HUMANA COMMERCIAL, 254.80,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10659,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,HUMANA,HUMANA COMMERCIAL, 92.12,,OUTPCT LIMIT, 50.83,OTHER, 20.72, 92.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10660,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,HUMANA,HUMANA COMMERCIAL, 106.82,,OUTPCT LIMIT, 59.00,OTHER, 24.26, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10661,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,HUMANA,HUMANA COMMERCIAL, 118.83,,OUTPCT LIMIT, 64.46,OTHER, 22.02, 118.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10662,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,HUMANA,HUMANA COMMERCIAL, 106.93,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10663,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,HUMANA,HUMANA COMMERCIAL, 106.93,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10664,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,HUMANA,HUMANA COMMERCIAL, 179.32,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10665,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,HUMANA,HUMANA COMMERCIAL, 107.93,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10666,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,HUMANA,HUMANA COMMERCIAL, 107.93,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10667,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,HUMANA,HUMANA COMMERCIAL, 120.54,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10668,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,HUMANA,HUMANA COMMERCIAL, 120.54,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10669,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,HUMANA,HUMANA COMMERCIAL, 77.42,,OUTPCT LIMIT, 43.51,OTHER, 20.72, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10670,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,HUMANA,HUMANA COMMERCIAL, 86.61,,OUTPCT LIMIT, 47.68,OTHER, 19.00, 86.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10671,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,HUMANA,HUMANA COMMERCIAL, 103.88,,OUTPCT LIMIT, 58.39,OTHER, 27.86, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10672,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,HUMANA,HUMANA COMMERCIAL, 145.98,,OUTPCT LIMIT, 77.47,OTHER, 19.86, 145.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10673,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,HUMANA,HUMANA COMMERCIAL, 116.00,,OUTPCT LIMIT, 62.50,OTHER, 19.74, 116.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10674,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,HUMANA,HUMANA COMMERCIAL, 85.52,,OUTPCT LIMIT, 46.75,OTHER, 17.35, 85.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10675,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,HUMANA,HUMANA COMMERCIAL, 74.48,,OUTPCT LIMIT, 41.14,OTHER, 16.94, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10676,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,HUMANA,HUMANA COMMERCIAL, 127.23,,OUTPCT LIMIT, 67.08,OTHER, 15.47, 127.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10677,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,HUMANA,HUMANA COMMERCIAL, 92.87,,OUTPCT LIMIT, 50.52,OTHER, 17.84, 92.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10678,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,HUMANA,HUMANA COMMERCIAL, 48.80,,OUTPCT LIMIT, 28.18,OTHER, 16.21, 48.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10679,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,HUMANA,HUMANA COMMERCIAL, 96.47,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10680,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,HUMANA,HUMANA COMMERCIAL, 96.47,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10681,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,HUMANA,HUMANA COMMERCIAL, 73.50,,OUTPCT LIMIT, 41.16,OTHER, 19.07, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10682,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,HUMANA,HUMANA COMMERCIAL, 82.64,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10683,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,HUMANA,HUMANA COMMERCIAL, 82.64,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10684,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,HUMANA,HUMANA COMMERCIAL, 82.64,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10685,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,HUMANA,HUMANA COMMERCIAL, 85.51,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10686,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,HUMANA,HUMANA COMMERCIAL, 88.45,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10687,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,HUMANA,HUMANA COMMERCIAL, 88.45,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10688,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,HUMANA,HUMANA COMMERCIAL, 89.99,,OUTPCT LIMIT, 49.38,OTHER, 19.07, 89.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10689,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,HUMANA,HUMANA COMMERCIAL, 151.91,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10690,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,HUMANA,HUMANA COMMERCIAL, 151.91,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10691,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,HUMANA,HUMANA COMMERCIAL, 717.15,,OUTPCT LIMIT, 361.76,OTHER, 18.55, 717.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10692,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,HUMANA,HUMANA COMMERCIAL, 314.58,,OUTPCT LIMIT, 161.64,OTHER, 20.54, 314.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10693,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,HUMANA,HUMANA COMMERCIAL, 274.17,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10694,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,HUMANA,HUMANA COMMERCIAL, 274.17,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10695,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,HUMANA,HUMANA COMMERCIAL, 149.84,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10696,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,HUMANA,HUMANA COMMERCIAL, 149.84,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10697,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,HUMANA,HUMANA COMMERCIAL, 149.84,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10698,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,HUMANA,HUMANA COMMERCIAL, 234.22,,OUTPCT LIMIT, 152.44,OTHER, 102.77, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10699,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,HUMANA,HUMANA COMMERCIAL, 422.24,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10700,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,HUMANA,HUMANA COMMERCIAL, 422.24,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10701,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,HUMANA,HUMANA COMMERCIAL, 422.24,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10702,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,HUMANA,HUMANA COMMERCIAL, 160.39,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10703,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,HUMANA,HUMANA COMMERCIAL, 160.39,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10704,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,HUMANA,HUMANA COMMERCIAL, 160.39,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10705,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,HUMANA,HUMANA COMMERCIAL, 160.39,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10706,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,HUMANA,HUMANA COMMERCIAL, 160.39,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10707,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,HUMANA,HUMANA COMMERCIAL, 291.17,,OUTPCT LIMIT, 146.86,OTHER, 7.46, 291.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10708,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,HUMANA,HUMANA COMMERCIAL, 107.80,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10709,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,HUMANA,HUMANA COMMERCIAL, 107.80,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10710,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,HUMANA,HUMANA COMMERCIAL, 107.80,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10711,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,HUMANA,HUMANA COMMERCIAL, 89.26,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10712,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,HUMANA,HUMANA COMMERCIAL, 84.83,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10713,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,HUMANA,HUMANA COMMERCIAL, 89.26,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10714,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,HUMANA,HUMANA COMMERCIAL, 422.24,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10715,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,HUMANA,HUMANA COMMERCIAL, 422.24,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10716,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,HUMANA,HUMANA COMMERCIAL, 383.67,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10717,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,HUMANA,HUMANA COMMERCIAL, 136.71,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10718,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,HUMANA,HUMANA COMMERCIAL, 136.71,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10719,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,HUMANA,HUMANA COMMERCIAL, 582.34,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10720,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,HUMANA,HUMANA COMMERCIAL, 582.34,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10721,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,HUMANA,HUMANA COMMERCIAL, 582.34,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10722,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,HUMANA,HUMANA COMMERCIAL, 582.34,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10723,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,HUMANA,HUMANA COMMERCIAL, 582.34,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10724,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,HUMANA,HUMANA COMMERCIAL, 582.34,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10725,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,HUMANA,HUMANA COMMERCIAL, 136.71,,OUTPCT LIMIT, 76.50,OTHER, 35.20, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10726,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,HUMANA,HUMANA COMMERCIAL, 255.78,,OUTPCT LIMIT, 149.18,OTHER, 91.25, 255.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10727,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,HUMANA,HUMANA COMMERCIAL, 156.27,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10728,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,HUMANA,HUMANA COMMERCIAL, 156.27,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10729,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,HUMANA,HUMANA COMMERCIAL, 55.24,,OUTPCT LIMIT, 30.76,OTHER, 13.60, 55.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10730,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,HUMANA,HUMANA COMMERCIAL, 139.85,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10731,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,HUMANA,HUMANA COMMERCIAL, 139.85,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10732,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,HUMANA,HUMANA COMMERCIAL, 150.55,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10733,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,HUMANA,HUMANA COMMERCIAL, 150.55,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10734,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,HUMANA,HUMANA COMMERCIAL, 152.97,,OUTPCT LIMIT, 78.99,OTHER, 11.64, 152.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10735,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,HUMANA,HUMANA COMMERCIAL, 88.31,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10736,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,HUMANA,HUMANA COMMERCIAL, 88.31,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10737,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,HUMANA,HUMANA COMMERCIAL, 88.31,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10738,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,HUMANA,HUMANA COMMERCIAL, 77.65,,OUTPCT LIMIT, 40.96,OTHER, 9.55, 77.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10739,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,HUMANA,HUMANA COMMERCIAL, 84.11,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10740,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,HUMANA,HUMANA COMMERCIAL, 84.11,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10741,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,HUMANA,HUMANA COMMERCIAL, 84.11,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10742,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,HUMANA,HUMANA COMMERCIAL, 159.52,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10743,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,HUMANA,HUMANA COMMERCIAL, 159.52,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10744,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,HUMANA,HUMANA COMMERCIAL, 144.22,,OUTPCT LIMIT, 74.74,OTHER, 12.11, 144.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10745,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,HUMANA,HUMANA COMMERCIAL, 175.20,,OUTPCT LIMIT, 91.00,OTHER, 15.55, 175.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10746,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,HUMANA,HUMANA COMMERCIAL, 130.97,,OUTPCT LIMIT, 68.31,OTHER, 12.82, 130.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10747,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,HUMANA,HUMANA COMMERCIAL, 32.34,,OUTPCT LIMIT, 17.74,OTHER, 6.84, 32.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10748,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,HUMANA,HUMANA COMMERCIAL, 40.99,,OUTPCT LIMIT, 22.99,OTHER, 10.78, 40.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10749,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,HUMANA,HUMANA COMMERCIAL, 56.84,,OUTPCT LIMIT, 29.95,OTHER, 6.84, 56.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10750,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,HUMANA,HUMANA COMMERCIAL, 79.16,,OUTPCT LIMIT, 42.41,OTHER, 12.46, 79.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10751,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,HUMANA,HUMANA COMMERCIAL, 55.46,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10752,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,HUMANA,HUMANA COMMERCIAL, 51.64,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10753,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,HUMANA,HUMANA COMMERCIAL, 51.64,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10754,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,HUMANA,HUMANA COMMERCIAL, 51.83,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10755,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,HUMANA,HUMANA COMMERCIAL, 51.83,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10756,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,HUMANA,HUMANA COMMERCIAL, 72.84,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10757,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,HUMANA,HUMANA COMMERCIAL, 72.84,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10758,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,HUMANA,HUMANA COMMERCIAL, 52.77,,OUTPCT LIMIT, 28.29,OTHER, 8.38, 52.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10759,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,HUMANA,HUMANA COMMERCIAL, 124.46,,OUTPCT LIMIT, 68.72,OTHER, 28.16, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10760,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,HUMANA,HUMANA COMMERCIAL, 592.61,,OUTPCT LIMIT, 299.39,OTHER, 17.26, 592.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10761,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,HUMANA,HUMANA COMMERCIAL, 74.50,,OUTPCT LIMIT, 40.67,OTHER, 14.88, 74.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10762,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,HUMANA,HUMANA COMMERCIAL, 78.52,,OUTPCT LIMIT, 43.08,OTHER, 16.61, 78.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10763,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,HUMANA,HUMANA COMMERCIAL, 234.22,,OUTPCT LIMIT, 121.25,OTHER, 19.08, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10764,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,HUMANA,HUMANA COMMERCIAL, 124.46,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10765,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,HUMANA,HUMANA COMMERCIAL, 189.14,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10766,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,HUMANA,HUMANA COMMERCIAL, 189.15,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10767,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,HUMANA,HUMANA COMMERCIAL, 189.14,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10768,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,HUMANA,HUMANA COMMERCIAL, 189.14,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10769,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,HUMANA,HUMANA COMMERCIAL, 189.14,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10770,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,HUMANA,HUMANA COMMERCIAL, 369.61,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10771,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,HUMANA,HUMANA COMMERCIAL, 369.61,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10772,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,HUMANA,HUMANA COMMERCIAL, 153.99,,OUTPCT LIMIT, 100.71,OTHER, 67.57, 153.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10773,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,HUMANA,HUMANA COMMERCIAL, 415.00,,OUTPCT LIMIT, 221.47,OTHER, 61.69, 415.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10774,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,HUMANA,HUMANA COMMERCIAL, 129.25,,OUTPCT LIMIT, 76.43,OTHER, 50.53, 129.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10775,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,HUMANA,HUMANA COMMERCIAL, 473.34,,OUTPCT LIMIT, 265.03,OTHER, 122.54, 473.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10776,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,HUMANA,HUMANA COMMERCIAL, 189.15,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10777,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,HUMANA,HUMANA COMMERCIAL, 147.00,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10778,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,HUMANA,HUMANA COMMERCIAL, 147.00,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10779,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,HUMANA,HUMANA COMMERCIAL, 607.66,,OUTPCT LIMIT, 445.68,OTHER, 266.63, 607.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10780,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,HUMANA,HUMANA COMMERCIAL, 98.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10781,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,HUMANA,HUMANA COMMERCIAL, 98.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10782,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,HUMANA,HUMANA COMMERCIAL, 98.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10783,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,HUMANA,HUMANA COMMERCIAL, 365.17,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10784,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,HUMANA,HUMANA COMMERCIAL, 365.17,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10785,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10786,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,HUMANA,HUMANA COMMERCIAL, 324.38,,OUTPCT LIMIT, 173.66,OTHER, 50.53, 324.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10787,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,HUMANA,HUMANA COMMERCIAL, 124.46,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10788,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,HUMANA,HUMANA COMMERCIAL, 171.70,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10789,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,HUMANA,HUMANA COMMERCIAL, 599.70,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10790,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,HUMANA,HUMANA COMMERCIAL, 264.57,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10791,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,HUMANA,HUMANA COMMERCIAL, 264.57,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10792,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,HUMANA,HUMANA COMMERCIAL, 113.55,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10793,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,HUMANA,HUMANA COMMERCIAL, 113.55,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10794,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,HUMANA,HUMANA COMMERCIAL, 77.42,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10795,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,HUMANA,HUMANA COMMERCIAL, 77.42,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10796,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,HUMANA,HUMANA COMMERCIAL, 77.42,,OUTPCT LIMIT, 44.25,OTHER, 23.81, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10797,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,HUMANA,HUMANA COMMERCIAL, 24.50,,OUTPCT LIMIT, 17.88,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10798,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,HUMANA,HUMANA COMMERCIAL, 189.91,,OUTPCT LIMIT, 100.14,OTHER, 23.14, 189.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10799,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,HUMANA,HUMANA COMMERCIAL, 1429.82,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10800,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,HUMANA,HUMANA COMMERCIAL, 1429.82,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10801,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,HUMANA,HUMANA COMMERCIAL, 101.92,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10802,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,HUMANA,HUMANA COMMERCIAL, 101.92,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10803,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,HUMANA,HUMANA COMMERCIAL, 543.90,,OUTPCT LIMIT, 294.34,OTHER, 97.97, 543.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10804,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10805,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10806,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,HUMANA,HUMANA COMMERCIAL, 30.38,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10807,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,HUMANA,HUMANA COMMERCIAL, 30.38,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10808,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,HUMANA,HUMANA COMMERCIAL, 110.16,,OUTPCT LIMIT, 56.81,OTHER, 8.06, 110.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10809,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,HUMANA,HUMANA COMMERCIAL, 75.19,,OUTPCT LIMIT, 39.98,OTHER, 10.56, 75.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10810,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,HUMANA,HUMANA COMMERCIAL, 75.46,,OUTPCT LIMIT, 41.73,OTHER, 17.35, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10811,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,HUMANA,HUMANA COMMERCIAL, 5813.78,,OUTPCT LIMIT, 3802.17,OTHER, 2550.94, 5813.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10812,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,HUMANA,HUMANA COMMERCIAL, 110.41,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10813,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,HUMANA,HUMANA COMMERCIAL, 110.41,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10814,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,HUMANA,HUMANA COMMERCIAL, 28.91,,OUTPCT LIMIT, 23.30,OTHER, 12.69, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10815,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,HUMANA,HUMANA COMMERCIAL, 58.31,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10816,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,HUMANA,HUMANA COMMERCIAL, 29.16,,OUTPCT LIMIT, 23.42,OTHER, 12.79, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10817,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,HUMANA,HUMANA COMMERCIAL, 126.42,,OUTPCT LIMIT, 82.68,OTHER, 55.47, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10818,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10819,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,HUMANA,HUMANA COMMERCIAL, 149.94,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10820,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,HUMANA,HUMANA COMMERCIAL, 149.94,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10821,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,HUMANA,HUMANA COMMERCIAL, 136.17,,OUTPCT LIMIT, 89.06,OTHER, 59.75, 136.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10822,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,HUMANA,HUMANA COMMERCIAL, 49.00,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10823,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,HUMANA,HUMANA COMMERCIAL, 49.00,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10824,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,HUMANA,HUMANA COMMERCIAL, 581.52,,OUTPCT LIMIT, 356.50,OTHER, 255.16, 581.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10825,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,HUMANA,HUMANA COMMERCIAL, 1214.99,,OUTPCT LIMIT, 687.64,OTHER, 345.38, 1214.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10826,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,HUMANA,HUMANA COMMERCIAL, 308.21,,OUTPCT LIMIT, 201.57,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10827,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10828,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10829,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,HUMANA,HUMANA COMMERCIAL, 83.30,,OUTPCT LIMIT, 60.00,OTHER, 36.55, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10830,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,HUMANA,HUMANA COMMERCIAL, 50.42,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10831,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,HUMANA,HUMANA COMMERCIAL, 50.42,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10832,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10833,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10834,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10835,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,HUMANA,HUMANA COMMERCIAL, 10.78,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10836,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,HUMANA,HUMANA COMMERCIAL, 10.78,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10837,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,HUMANA,HUMANA COMMERCIAL, 10.78,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10838,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,HUMANA,HUMANA COMMERCIAL, 10.78,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10839,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,HUMANA,HUMANA COMMERCIAL, 78.15,,OUTPCT LIMIT, 51.11,OTHER, 34.29, 78.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10840,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,HUMANA,HUMANA COMMERCIAL, 133.98,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10841,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,HUMANA,HUMANA COMMERCIAL, 133.98,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10842,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10843,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,HUMANA,HUMANA COMMERCIAL, 154.64,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10844,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,HUMANA,HUMANA COMMERCIAL, 154.64,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10845,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10846,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10847,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,HUMANA,HUMANA COMMERCIAL, 167.49,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10848,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,HUMANA,HUMANA COMMERCIAL, 167.49,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10849,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,HUMANA,HUMANA COMMERCIAL, 9.80,,OUTPCT LIMIT, 12.78,OTHER, 4.30, 33.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10850,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,HUMANA,HUMANA COMMERCIAL, 32.40,,OUTPCT LIMIT, 17.36,OTHER, 5.09, 32.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10851,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,HUMANA,HUMANA COMMERCIAL, 297.83,,OUTPCT LIMIT, 184.48,OTHER, 130.68, 297.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10852,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,HUMANA,HUMANA COMMERCIAL, 333.70,,OUTPCT LIMIT, 202.35,OTHER, 146.42, 333.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10853,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,HUMANA,HUMANA COMMERCIAL, 144.98,,OUTPCT LIMIT, 99.37,OTHER, 63.61, 144.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10854,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,HUMANA,HUMANA COMMERCIAL, 149.03,,OUTPCT LIMIT, 88.44,OTHER, 59.56, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10855,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,HUMANA,HUMANA COMMERCIAL, 191.95,,OUTPCT LIMIT, 131.72,OTHER, 84.22, 191.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10856,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,HUMANA,HUMANA COMMERCIAL, 188.72,,OUTPCT LIMIT, 117.05,OTHER, 82.81, 188.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10857,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,HUMANA,HUMANA COMMERCIAL, 288.34,,OUTPCT LIMIT, 179.75,OTHER, 126.51, 288.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10858,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,HUMANA,HUMANA COMMERCIAL, 249.46,,OUTPCT LIMIT, 158.52,OTHER, 109.46, 249.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10859,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,HUMANA,HUMANA COMMERCIAL, 301.30,,OUTPCT LIMIT, 186.21,OTHER, 132.20, 301.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10860,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,HUMANA,HUMANA COMMERCIAL, 144.17,,OUTPCT LIMIT, 83.96,OTHER, 50.93, 144.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10861,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,HUMANA,HUMANA COMMERCIAL, 232.46,,OUTPCT LIMIT, 167.44,OTHER, 102.00, 232.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10862,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,HUMANA,HUMANA COMMERCIAL, 242.17,,OUTPCT LIMIT, 172.28,OTHER, 106.26, 242.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10863,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,HUMANA,HUMANA COMMERCIAL, 58.32,,OUTPCT LIMIT, 49.86,OTHER, 25.59, 87.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10864,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,HUMANA,HUMANA COMMERCIAL, 242.98,,OUTPCT LIMIT, 141.43,OTHER, 85.51, 242.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10865,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,HUMANA,HUMANA COMMERCIAL, 103.51,,OUTPCT LIMIT, 69.71,OTHER, 45.42, 103.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10866,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,HUMANA,HUMANA COMMERCIAL, 274.57,,OUTPCT LIMIT, 177.65,OTHER, 120.47, 274.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10867,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,HUMANA,HUMANA COMMERCIAL, 298.25,,OUTPCT LIMIT, 189.46,OTHER, 130.87, 298.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10868,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,HUMANA,HUMANA COMMERCIAL, 479.83,,OUTPCT LIMIT, 279.93,OTHER, 171.54, 479.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10869,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,HUMANA,HUMANA COMMERCIAL, 449.86,,OUTPCT LIMIT, 265.00,OTHER, 171.54, 449.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10870,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,HUMANA,HUMANA COMMERCIAL, 246.56,,OUTPCT LIMIT, 149.90,OTHER, 108.18, 246.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10871,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,HUMANA,HUMANA COMMERCIAL, 313.16,,OUTPCT LIMIT, 167.02,OTHER, 46.09, 313.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10872,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,HUMANA,HUMANA COMMERCIAL, 130.70,,OUTPCT LIMIT, 76.10,OTHER, 46.09, 130.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10873,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,HUMANA,HUMANA COMMERCIAL, 273.68,,OUTPCT LIMIT, 147.35,OTHER, 46.09, 273.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10874,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,HUMANA,HUMANA COMMERCIAL, 396.61,,OUTPCT LIMIT, 227.22,OTHER, 124.32, 396.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10875,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,HUMANA,HUMANA COMMERCIAL, 533.61,,OUTPCT LIMIT, 295.49,OTHER, 124.32, 533.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10876,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,HUMANA,HUMANA COMMERCIAL, 170.18,,OUTPCT LIMIT, 114.40,OTHER, 74.67, 170.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10877,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,HUMANA,HUMANA COMMERCIAL, 252.63,,OUTPCT LIMIT, 155.48,OTHER, 110.85, 252.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10878,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,HUMANA,HUMANA COMMERCIAL, 39.15,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10879,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,HUMANA,HUMANA COMMERCIAL, 39.15,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10880,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,HUMANA,HUMANA COMMERCIAL, 39.15,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10881,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,HUMANA,HUMANA COMMERCIAL, 19.16,,OUTPCT LIMIT, 36.72,OTHER, 8.41, 114.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10882,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,HUMANA,HUMANA COMMERCIAL, 360.98,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10883,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,HUMANA,HUMANA COMMERCIAL, 360.98,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10884,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,HUMANA,HUMANA COMMERCIAL, 891.44,,OUTPCT LIMIT, 526.62,OTHER, 346.21, 891.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10885,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 290.83,OTHER, 143.52, 346.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10886,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,HUMANA,HUMANA COMMERCIAL, 326.60,,OUTPCT LIMIT, 266.67,OTHER, 147.17, 326.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10887,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,HUMANA,HUMANA COMMERCIAL, 301.84,,OUTPCT LIMIT, 162.12,OTHER, 49.24, 301.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10888,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,HUMANA,HUMANA COMMERCIAL, 243.04,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10889,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,HUMANA,HUMANA COMMERCIAL, 243.04,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10890,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,HUMANA,HUMANA COMMERCIAL, 310.66,,OUTPCT LIMIT, 166.97,OTHER, 51.13, 310.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10891,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,HUMANA,HUMANA COMMERCIAL, 85.86,,OUTPCT LIMIT, 54.96,OTHER, 37.67, 85.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10892,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,HUMANA,HUMANA COMMERCIAL, 149.03,,OUTPCT LIMIT, 86.43,OTHER, 51.13, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10893,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,HUMANA,HUMANA COMMERCIAL, 1594.15,,OUTPCT LIMIT, 950.56,OTHER, 656.16, 1594.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10894,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 375.80,OTHER, 121.44, 656.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10895,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,HUMANA,HUMANA COMMERCIAL, 911.40,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10896,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,HUMANA,HUMANA COMMERCIAL, 911.40,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10897,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10898,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10899,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,HUMANA,HUMANA COMMERCIAL, 1080.22,,OUTPCT LIMIT, 591.97,OTHER, 225.62, 1080.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10900,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10901,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,HUMANA,HUMANA COMMERCIAL, 456.38,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10902,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,HUMANA,HUMANA COMMERCIAL, 456.38,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10903,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 197.77,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10904,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,HUMANA,HUMANA COMMERCIAL, 1023.38,,OUTPCT LIMIT, 563.65,OTHER, 225.62, 1023.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10905,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10906,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,HUMANA,HUMANA COMMERCIAL, 159.74,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10907,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,HUMANA,HUMANA COMMERCIAL, 159.74,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10908,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10909,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10910,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,HUMANA,HUMANA COMMERCIAL, 490.00,,OUTPCT LIMIT, 297.88,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10911,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10912,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,HUMANA,HUMANA COMMERCIAL, 458.40,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10913,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,HUMANA,HUMANA COMMERCIAL, 458.40,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10914,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10915,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10916,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,HUMANA,HUMANA COMMERCIAL, 1244.07,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10917,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,HUMANA,HUMANA COMMERCIAL, 1244.07,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10918,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,HUMANA,HUMANA COMMERCIAL, 660.99,,OUTPCT LIMIT, 383.08,OTHER, 225.62, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10919,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,HUMANA,HUMANA COMMERCIAL, 1244.07,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10920,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10921,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10922,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10923,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10924,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,HUMANA,HUMANA COMMERCIAL, 660.99,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10925,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,HUMANA,HUMANA COMMERCIAL, 660.99,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10926,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,HUMANA,HUMANA COMMERCIAL, 660.99,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10927,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,HUMANA,HUMANA COMMERCIAL, 660.99,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10928,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10929,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10930,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10931,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10932,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,HUMANA,HUMANA COMMERCIAL, 1207.49,,OUTPCT LIMIT, 655.39,OTHER, 225.62, 1207.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10933,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10934,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,HUMANA,HUMANA COMMERCIAL, 2539.18,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10935,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,HUMANA,HUMANA COMMERCIAL, 1371.49,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10936,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,HUMANA,HUMANA COMMERCIAL, 427.28,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10937,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,HUMANA,HUMANA COMMERCIAL, 90.16,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10938,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,HUMANA,HUMANA COMMERCIAL, 1032.31,,OUTPCT LIMIT, 547.41,OTHER, 138.71, 1032.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10939,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,HUMANA,HUMANA COMMERCIAL, 236.76,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10940,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,HUMANA,HUMANA COMMERCIAL, 236.76,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10941,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,HUMANA,HUMANA COMMERCIAL, 286.68,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10942,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,HUMANA,HUMANA COMMERCIAL, 286.68,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10943,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,HUMANA,HUMANA COMMERCIAL, 600.12,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10944,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,HUMANA,HUMANA COMMERCIAL, 786.94,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10945,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,HUMANA,HUMANA COMMERCIAL, 864.36,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10946,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,HUMANA,HUMANA COMMERCIAL, 600.12,,OUTPCT LIMIT, 332.46,OTHER, 140.42, 600.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10947,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,HUMANA,HUMANA COMMERCIAL, 365.30,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10948,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,HUMANA,HUMANA COMMERCIAL, 365.30,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10949,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,HUMANA,HUMANA COMMERCIAL, 236.76,,OUTPCT LIMIT, 174.98,OTHER, 103.88, 239.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10950,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,HUMANA,HUMANA COMMERCIAL, 236.76,,OUTPCT LIMIT, 136.10,OTHER, 76.16, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10951,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,HUMANA,HUMANA COMMERCIAL, 169.54,,OUTPCT LIMIT, 140.33,OTHER, 74.39, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10952,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,HUMANA,HUMANA COMMERCIAL, 416.50,,OUTPCT LIMIT, 228.33,OTHER, 87.35, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10953,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,HUMANA,HUMANA COMMERCIAL, 52.27,,OUTPCT LIMIT, 34.19,OTHER, 22.94, 52.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10954,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,HUMANA,HUMANA COMMERCIAL, 101.92,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10955,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,HUMANA,HUMANA COMMERCIAL, 321.10,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10956,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,HUMANA,HUMANA COMMERCIAL, 321.10,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10957,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,HUMANA,HUMANA COMMERCIAL, 140.56,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10958,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,HUMANA,HUMANA COMMERCIAL, 140.56,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10959,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,HUMANA,HUMANA COMMERCIAL, 721.47,,OUTPCT LIMIT, 415.63,OTHER, 235.80, 721.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10960,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,HUMANA,HUMANA COMMERCIAL, 3185.00,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10961,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,HUMANA,HUMANA COMMERCIAL, 3185.00,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10962,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,HUMANA,HUMANA COMMERCIAL, 3822.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10963,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,HUMANA,HUMANA COMMERCIAL, 3822.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10964,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,HUMANA,HUMANA COMMERCIAL, 3822.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10965,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,HUMANA,HUMANA COMMERCIAL, 265.80,,OUTPCT LIMIT, 152.82,OTHER, 85.61, 265.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10966,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,HUMANA,HUMANA COMMERCIAL, 290.35,,OUTPCT LIMIT, 165.98,OTHER, 89.47, 290.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10967,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,HUMANA,HUMANA COMMERCIAL, 470.66,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10968,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,HUMANA,HUMANA COMMERCIAL, 470.66,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10969,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,HUMANA,HUMANA COMMERCIAL, 176.60,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10970,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,HUMANA,HUMANA COMMERCIAL, 176.60,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10971,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,HUMANA,HUMANA COMMERCIAL, 560.23,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10972,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,HUMANA,HUMANA COMMERCIAL, 560.23,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10973,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,HUMANA,HUMANA COMMERCIAL, 560.23,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10974,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,HUMANA,HUMANA COMMERCIAL, 161.41,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10975,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,HUMANA,HUMANA COMMERCIAL, 161.47,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10976,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,HUMANA,HUMANA COMMERCIAL, 192.50,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10977,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,HUMANA,HUMANA COMMERCIAL, 192.50,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10978,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,HUMANA,HUMANA COMMERCIAL, 141.06,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10979,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,HUMANA,HUMANA COMMERCIAL, 141.06,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10980,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,HUMANA,HUMANA COMMERCIAL, 150.81,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10981,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,HUMANA,HUMANA COMMERCIAL, 150.81,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10982,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,HUMANA,HUMANA COMMERCIAL, 58.31,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10983,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,HUMANA,HUMANA COMMERCIAL, 58.31,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10984,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,HUMANA,HUMANA COMMERCIAL, 294.82,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10985,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,HUMANA,HUMANA COMMERCIAL, 294.82,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10986,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,HUMANA,HUMANA COMMERCIAL, 167.51,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10987,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,HUMANA,HUMANA COMMERCIAL, 167.51,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10988,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,HUMANA,HUMANA COMMERCIAL, 169.05,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10989,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,HUMANA,HUMANA COMMERCIAL, 169.05,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10990,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,HUMANA,HUMANA COMMERCIAL, 86.20,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10991,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,HUMANA,HUMANA COMMERCIAL, 86.20,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10992,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,HUMANA,HUMANA COMMERCIAL, 94.61,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10993,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,HUMANA,HUMANA COMMERCIAL, 94.61,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10994,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,HUMANA,HUMANA COMMERCIAL, 103.67,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10995,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,HUMANA,HUMANA COMMERCIAL, 103.67,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10996,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,HUMANA,HUMANA COMMERCIAL, 103.67,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10997,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,HUMANA,HUMANA COMMERCIAL, 411.60,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10998,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,HUMANA,HUMANA COMMERCIAL, 132.15,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 10999,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,HUMANA,HUMANA COMMERCIAL, 132.15,,OUTPCT LIMIT, 72.71,OTHER, 28.82, 132.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11000,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,HUMANA,HUMANA COMMERCIAL, 120.42,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11001,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,HUMANA,HUMANA COMMERCIAL, 120.34,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11002,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,HUMANA,HUMANA COMMERCIAL, 120.42,,OUTPCT LIMIT, 74.35,OTHER, 52.84, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11003,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,HUMANA,HUMANA COMMERCIAL, 128.44,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11004,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,HUMANA,HUMANA COMMERCIAL, 128.44,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11005,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,HUMANA,HUMANA COMMERCIAL, 128.44,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11006,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,HUMANA,HUMANA COMMERCIAL, 93.23,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11007,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,HUMANA,HUMANA COMMERCIAL, 93.23,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11008,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,HUMANA,HUMANA COMMERCIAL, 66.27,,OUTPCT LIMIT, 47.68,OTHER, 29.08, 66.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11009,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,HUMANA,HUMANA COMMERCIAL, 175.42,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11010,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,HUMANA,HUMANA COMMERCIAL, 175.42,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11011,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,HUMANA,HUMANA COMMERCIAL, 175.42,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11012,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,HUMANA,HUMANA COMMERCIAL, 210.70,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11013,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,HUMANA,HUMANA COMMERCIAL, 210.70,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11014,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,HUMANA,HUMANA COMMERCIAL, 210.70,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11015,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,HUMANA,HUMANA COMMERCIAL, 120.22,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11016,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,HUMANA,HUMANA COMMERCIAL, 120.22,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11017,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,HUMANA,HUMANA COMMERCIAL, 120.22,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11018,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,HUMANA,HUMANA COMMERCIAL, 43.12,,OUTPCT LIMIT, 30.33,OTHER, 18.92, 43.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11019,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,HUMANA,HUMANA COMMERCIAL, 259.74,,OUTPCT LIMIT, 178.52,OTHER, 113.97, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11020,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,HUMANA,HUMANA COMMERCIAL, 308.21,,OUTPCT LIMIT, 202.67,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11021,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,HUMANA,HUMANA COMMERCIAL, 291.81,,OUTPCT LIMIT, 194.50,OTHER, 128.04, 291.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11022,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,HUMANA,HUMANA COMMERCIAL, 145.39,,OUTPCT LIMIT, 106.37,OTHER, 63.79, 145.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11023,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,HUMANA,HUMANA COMMERCIAL, 249.24,,OUTPCT LIMIT, 173.75,OTHER, 109.36, 249.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11024,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,HUMANA,HUMANA COMMERCIAL, 263.46,,OUTPCT LIMIT, 180.83,OTHER, 115.60, 263.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11025,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,HUMANA,HUMANA COMMERCIAL, 310.94,,OUTPCT LIMIT, 204.49,OTHER, 136.43, 310.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11026,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,HUMANA,HUMANA COMMERCIAL, 150.18,,OUTPCT LIMIT, 108.91,OTHER, 65.89, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11027,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,HUMANA,HUMANA COMMERCIAL, 118.30,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11028,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,HUMANA,HUMANA COMMERCIAL, 118.30,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11029,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,HUMANA,HUMANA COMMERCIAL, 118.30,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11030,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,HUMANA,HUMANA COMMERCIAL, 71.93,,OUTPCT LIMIT, 44.69,OTHER, 31.56, 71.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11031,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,HUMANA,HUMANA COMMERCIAL, 125.10,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11032,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,HUMANA,HUMANA COMMERCIAL, 125.10,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11033,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,HUMANA,HUMANA COMMERCIAL, 86.85,,OUTPCT LIMIT, 59.17,OTHER, 38.11, 86.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11034,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,HUMANA,HUMANA COMMERCIAL, 113.68,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11035,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,HUMANA,HUMANA COMMERCIAL, 113.68,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11036,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,HUMANA,HUMANA COMMERCIAL, 113.68,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11037,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,HUMANA,HUMANA COMMERCIAL, 28.42,,OUTPCT LIMIT, 68.90,OTHER, 12.81, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11038,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,HUMANA,HUMANA COMMERCIAL, 140.88,,OUTPCT LIMIT, 93.12,OTHER, 61.82, 140.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11039,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,HUMANA,HUMANA COMMERCIAL, 118.58,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11040,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,HUMANA,HUMANA COMMERCIAL, 259.74,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11041,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,HUMANA,HUMANA COMMERCIAL, 121.52,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11042,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,HUMANA,HUMANA COMMERCIAL, 121.52,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11043,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,HUMANA,HUMANA COMMERCIAL, 121.52,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11044,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,HUMANA,HUMANA COMMERCIAL, 73.50,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11045,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,HUMANA,HUMANA COMMERCIAL, 101.92,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11046,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,HUMANA,HUMANA COMMERCIAL, 138.18,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11047,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,HUMANA,HUMANA COMMERCIAL, 101.92,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11048,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,HUMANA,HUMANA COMMERCIAL, 138.18,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11049,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,HUMANA,HUMANA COMMERCIAL, 73.50,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11050,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,HUMANA,HUMANA COMMERCIAL, 73.50,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11051,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,HUMANA,HUMANA COMMERCIAL, 294.00,,OUTPCT LIMIT, 192.27,OTHER, 129.00, 294.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11052,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11053,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11054,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,HUMANA,HUMANA COMMERCIAL, 236.76,,OUTPCT LIMIT, 145.27,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11055,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,HUMANA,HUMANA COMMERCIAL, 145.78,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11056,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,HUMANA,HUMANA COMMERCIAL, 145.78,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11057,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,HUMANA,HUMANA COMMERCIAL, 247.03,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11058,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,HUMANA,HUMANA COMMERCIAL, 247.03,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11059,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,HUMANA,HUMANA COMMERCIAL, 386.51,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11060,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,HUMANA,HUMANA COMMERCIAL, 386.51,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11061,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,HUMANA,HUMANA COMMERCIAL, 481.47,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11062,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,HUMANA,HUMANA COMMERCIAL, 481.47,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11063,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,HUMANA,HUMANA COMMERCIAL, 46.65,,OUTPCT LIMIT, 30.51,OTHER, 20.47, 46.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11064,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,HUMANA,HUMANA COMMERCIAL, 101.63,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11065,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,HUMANA,HUMANA COMMERCIAL, 101.63,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11066,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,HUMANA,HUMANA COMMERCIAL, 169.93,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11067,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,HUMANA,HUMANA COMMERCIAL, 169.93,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11068,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,HUMANA,HUMANA COMMERCIAL, 250.73,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11069,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,HUMANA,HUMANA COMMERCIAL, 250.73,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11070,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,HUMANA,HUMANA COMMERCIAL, 335.70,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11071,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,HUMANA,HUMANA COMMERCIAL, 335.70,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11072,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,HUMANA,HUMANA COMMERCIAL, 333.20,,OUTPCT LIMIT, 272.06,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11073,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,HUMANA,HUMANA COMMERCIAL, 412.58,,OUTPCT LIMIT, 336.87,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11074,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,HUMANA,HUMANA COMMERCIAL, 142.10,,OUTPCT LIMIT, 111.61,OTHER, 64.03, 142.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11075,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,HUMANA,HUMANA COMMERCIAL, 173.46,,OUTPCT LIMIT, 149.82,OTHER, 78.16, 173.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11076,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,HUMANA,HUMANA COMMERCIAL, 250.88,,OUTPCT LIMIT, 220.11,OTHER, 113.05, 250.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11077,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,HUMANA,HUMANA COMMERCIAL, 263.54,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11078,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,HUMANA,HUMANA COMMERCIAL, 263.54,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11079,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,HUMANA,HUMANA COMMERCIAL, 245.98,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11080,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,HUMANA,HUMANA COMMERCIAL, 245.98,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11081,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,HUMANA,HUMANA COMMERCIAL, 407.68,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11082,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,HUMANA,HUMANA COMMERCIAL, 407.68,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11083,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,HUMANA,HUMANA COMMERCIAL, 290.08,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11084,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,HUMANA,HUMANA COMMERCIAL, 290.08,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11085,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,HUMANA,HUMANA COMMERCIAL, 644.19,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11086,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,HUMANA,HUMANA COMMERCIAL, 644.19,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11087,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,HUMANA,HUMANA COMMERCIAL, 333.20,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11088,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,HUMANA,HUMANA COMMERCIAL, 333.20,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11089,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,HUMANA,HUMANA COMMERCIAL, 1010.45,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11090,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,HUMANA,HUMANA COMMERCIAL, 1010.45,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11091,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,HUMANA,HUMANA COMMERCIAL, 412.58,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11092,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,HUMANA,HUMANA COMMERCIAL, 412.58,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11093,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,HUMANA,HUMANA COMMERCIAL, 1685.38,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11094,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,HUMANA,HUMANA COMMERCIAL, 1685.38,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11095,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,HUMANA,HUMANA COMMERCIAL, 490.98,,OUTPCT LIMIT, 429.06,OTHER, 221.24, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11096,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,HUMANA,HUMANA COMMERCIAL, 2695.76,,OUTPCT LIMIT, 1514.86,OTHER, 720.78, 2695.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11097,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,HUMANA,HUMANA COMMERCIAL, 988.24,,OUTPCT LIMIT, 646.30,OTHER, 433.62, 988.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11098,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,HUMANA,HUMANA COMMERCIAL, 29.40,,OUTPCT LIMIT, 19.23,OTHER, 12.90, 29.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11099,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,HUMANA,HUMANA COMMERCIAL, 164.10,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11100,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,HUMANA,HUMANA COMMERCIAL, 164.10,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11101,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,HUMANA,HUMANA COMMERCIAL, 258.23,,OUTPCT LIMIT, 167.97,OTHER, 113.31, 258.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11102,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,HUMANA,HUMANA COMMERCIAL, 269.06,,OUTPCT LIMIT, 173.37,OTHER, 118.06, 269.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11103,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,HUMANA,HUMANA COMMERCIAL, 280.72,,OUTPCT LIMIT, 179.18,OTHER, 123.17, 280.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11104,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,HUMANA,HUMANA COMMERCIAL, 317.37,,OUTPCT LIMIT, 197.44,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11105,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,HUMANA,HUMANA COMMERCIAL, 308.21,,OUTPCT LIMIT, 192.88,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11106,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,HUMANA,HUMANA COMMERCIAL, 355.69,,OUTPCT LIMIT, 232.62,OTHER, 156.07, 355.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11107,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,HUMANA,HUMANA COMMERCIAL, 386.51,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11108,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,HUMANA,HUMANA COMMERCIAL, 232.41,,OUTPCT LIMIT, 155.10,OTHER, 101.97, 232.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11109,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,HUMANA,HUMANA COMMERCIAL, 248.23,,OUTPCT LIMIT, 162.99,OTHER, 108.92, 248.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11110,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,HUMANA,HUMANA COMMERCIAL, 270.73,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11111,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,HUMANA,HUMANA COMMERCIAL, 270.73,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11112,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,HUMANA,HUMANA COMMERCIAL, 270.73,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11113,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,HUMANA,HUMANA COMMERCIAL, 276.56,,OUTPCT LIMIT, 177.10,OTHER, 121.35, 276.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11114,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,HUMANA,HUMANA COMMERCIAL, 294.88,,OUTPCT LIMIT, 192.85,OTHER, 129.39, 294.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11115,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,HUMANA,HUMANA COMMERCIAL, 317.37,,OUTPCT LIMIT, 207.56,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11116,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,HUMANA,HUMANA COMMERCIAL, 84.97,,OUTPCT LIMIT, 55.57,OTHER, 37.28, 84.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11117,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,HUMANA,HUMANA COMMERCIAL, 145.78,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11118,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,HUMANA,HUMANA COMMERCIAL, 68.60,,OUTPCT LIMIT, 44.86,OTHER, 30.10, 68.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11119,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,HUMANA,HUMANA COMMERCIAL, 260.73,,OUTPCT LIMIT, 170.52,OTHER, 114.40, 260.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11120,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,HUMANA,HUMANA COMMERCIAL, 51.82,,OUTPCT LIMIT, 33.14,OTHER, 22.74, 51.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11121,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,HUMANA,HUMANA COMMERCIAL, 64.14,,OUTPCT LIMIT, 39.28,OTHER, 28.14, 64.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11122,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,HUMANA,HUMANA COMMERCIAL, 92.49,,OUTPCT LIMIT, 60.49,OTHER, 40.58, 92.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11123,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,HUMANA,HUMANA COMMERCIAL, 21.56,,OUTPCT LIMIT, 14.10,OTHER, 9.46, 21.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11124,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,HUMANA,HUMANA COMMERCIAL, 21.56,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11125,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,HUMANA,HUMANA COMMERCIAL, 145.78,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11126,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,HUMANA,HUMANA COMMERCIAL, 249.90,,OUTPCT LIMIT, 148.65,OTHER, 101.33, 249.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11127,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,HUMANA,HUMANA COMMERCIAL, 269.50,,OUTPCT LIMIT, 166.04,OTHER, 118.25, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11128,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,HUMANA,HUMANA COMMERCIAL, 12.50,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11129,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,HUMANA,HUMANA COMMERCIAL, 12.50,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11130,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,HUMANA,HUMANA COMMERCIAL, 377.30,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11131,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,HUMANA,HUMANA COMMERCIAL, 377.30,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11132,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,HUMANA,HUMANA COMMERCIAL, 594.86,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11133,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,HUMANA,HUMANA COMMERCIAL, 594.86,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11134,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,HUMANA,HUMANA COMMERCIAL, 347.90,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11135,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,HUMANA,HUMANA COMMERCIAL, 347.90,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11136,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,HUMANA,HUMANA COMMERCIAL, 501.76,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11137,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,HUMANA,HUMANA COMMERCIAL, 501.76,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11138,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,HUMANA,HUMANA COMMERCIAL, 860.44,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11139,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,HUMANA,HUMANA COMMERCIAL, 860.44,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11140,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,HUMANA,HUMANA COMMERCIAL, 955.50,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11141,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,HUMANA,HUMANA COMMERCIAL, 955.50,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11142,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,HUMANA,HUMANA COMMERCIAL, 133.28,,OUTPCT LIMIT, 87.16,OTHER, 58.48, 133.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11143,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,HUMANA,HUMANA COMMERCIAL, 62.72,,OUTPCT LIMIT, 41.02,OTHER, 27.52, 62.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11144,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,HUMANA,HUMANA COMMERCIAL, 73.50,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11145,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,HUMANA,HUMANA COMMERCIAL, 2936.08,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11146,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,HUMANA,HUMANA COMMERCIAL, 2936.08,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11147,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,HUMANA,HUMANA COMMERCIAL, 3195.78,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11148,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,HUMANA,HUMANA COMMERCIAL, 3195.78,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11149,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,HUMANA,HUMANA COMMERCIAL, 2254.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11150,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,HUMANA,HUMANA COMMERCIAL, 2254.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11151,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,HUMANA,HUMANA COMMERCIAL, 2254.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11152,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,HUMANA,HUMANA COMMERCIAL, 1960.00,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11153,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,HUMANA,HUMANA COMMERCIAL, 1960.00,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11154,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,HUMANA,HUMANA COMMERCIAL, 1960.00,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11155,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,HUMANA,HUMANA COMMERCIAL, 1960.00,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11156,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,HUMANA,HUMANA COMMERCIAL, 18.76,,OUTPCT LIMIT, 9.74,OTHER, 1.66, 18.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11157,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,HUMANA,HUMANA COMMERCIAL, 110.41,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11158,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,HUMANA,HUMANA COMMERCIAL, 5.88,,OUTPCT LIMIT, 11.82,OTHER, 2.58, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11159,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,HUMANA,HUMANA COMMERCIAL, 88.30,,OUTPCT LIMIT, 57.75,OTHER, 38.74, 88.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11160,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,HUMANA,HUMANA COMMERCIAL, 45.82,,OUTPCT LIMIT, 29.96,OTHER, 20.10, 45.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11161,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,HUMANA,HUMANA COMMERCIAL, 162.00,,OUTPCT LIMIT, 88.75,OTHER, 33.71, 162.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11162,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,HUMANA,HUMANA COMMERCIAL, 101.92,,OUTPCT LIMIT, 58.81,OTHER, 33.71, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11163,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,HUMANA,HUMANA COMMERCIAL, 383.18,,OUTPCT LIMIT, 250.60,OTHER, 168.13, 383.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11164,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,HUMANA,HUMANA COMMERCIAL, 386.51,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11165,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,HUMANA,HUMANA COMMERCIAL, 386.51,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11166,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,HUMANA,HUMANA COMMERCIAL, 41.65,,OUTPCT LIMIT, 35.44,OTHER, 18.28, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11167,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,HUMANA,HUMANA COMMERCIAL, 59.98,,OUTPCT LIMIT, 44.57,OTHER, 26.32, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11168,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,HUMANA,HUMANA COMMERCIAL, 66.64,,OUTPCT LIMIT, 43.58,OTHER, 29.24, 66.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11169,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11170,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,HUMANA,HUMANA COMMERCIAL, 254.60,,OUTPCT LIMIT, 166.51,OTHER, 111.71, 254.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11171,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,HUMANA,HUMANA COMMERCIAL, 91.89,,OUTPCT LIMIT, 60.10,OTHER, 40.32, 91.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11172,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,HUMANA,HUMANA COMMERCIAL, 7.53,,OUTPCT LIMIT, 4.92,OTHER, 3.30, 7.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11173,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,HUMANA,HUMANA COMMERCIAL, 7.29,,OUTPCT LIMIT, 4.77,OTHER, 3.20, 7.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11174,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,HUMANA,HUMANA COMMERCIAL, 19.91,,OUTPCT LIMIT, 13.02,OTHER, 8.74, 19.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11175,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,HUMANA,HUMANA COMMERCIAL, 205.80,,OUTPCT LIMIT, 134.59,OTHER, 90.30, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11176,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,HUMANA,HUMANA COMMERCIAL, 2.08,,OUTPCT LIMIT, 1.36,OTHER, .91, 2.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11177,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,HUMANA,HUMANA COMMERCIAL, 3.21,,OUTPCT LIMIT, 2.10,OTHER, 1.41, 3.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11178,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,HUMANA,HUMANA COMMERCIAL, 39.62,,OUTPCT LIMIT, 25.91,OTHER, 17.38, 39.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11179,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,HUMANA,HUMANA COMMERCIAL, 142.21,,OUTPCT LIMIT, 93.00,OTHER, 62.40, 142.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11180,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,HUMANA,HUMANA COMMERCIAL, 2.23,,OUTPCT LIMIT, 1.46,OTHER, .98, 2.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11181,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,HUMANA,HUMANA COMMERCIAL, 1.57,,OUTPCT LIMIT, 1.03,OTHER, .69, 1.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11182,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,HUMANA,HUMANA COMMERCIAL, 7.88,,OUTPCT LIMIT, 5.15,OTHER, 3.46, 7.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11183,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,HUMANA,HUMANA COMMERCIAL, 17.52,,OUTPCT LIMIT, 11.46,OTHER, 7.69, 17.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11184,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,HUMANA,HUMANA COMMERCIAL, 6.70,,OUTPCT LIMIT, 4.38,OTHER, 2.94, 6.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11185,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,HUMANA,HUMANA COMMERCIAL, 3.92,,OUTPCT LIMIT, 2.56,OTHER, 1.72, 3.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11186,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,HUMANA,HUMANA COMMERCIAL, 11.45,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11187,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,HUMANA,HUMANA COMMERCIAL, 12.74,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11188,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,HUMANA,HUMANA COMMERCIAL, 66.95,,OUTPCT LIMIT, 43.79,OTHER, 29.38, 66.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11189,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,HUMANA,HUMANA COMMERCIAL, 35.20,,OUTPCT LIMIT, 23.02,OTHER, 15.45, 35.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11190,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,HUMANA,HUMANA COMMERCIAL, 10.31,,OUTPCT LIMIT, 6.74,OTHER, 4.52, 10.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11191,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,HUMANA,HUMANA COMMERCIAL, 7.96,,OUTPCT LIMIT, 5.20,OTHER, 3.49, 7.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11192,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,HUMANA,HUMANA COMMERCIAL, 391.02,,OUTPCT LIMIT, 575.18,OTHER, 171.57, 1597.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11193,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,HUMANA,HUMANA COMMERCIAL, 391.02,,OUTPCT LIMIT, 690.66,OTHER, 171.57, 2082.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11194,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,HUMANA,HUMANA COMMERCIAL, 391.02,,OUTPCT LIMIT, 656.15,OTHER, 171.57, 1937.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11195,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,HUMANA,HUMANA COMMERCIAL, 391.02,,OUTPCT LIMIT, 607.70,OTHER, 171.57, 1734.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11196,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,HUMANA,HUMANA COMMERCIAL, 489.02,,OUTPCT LIMIT, 735.35,OTHER, 214.57, 2065.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11197,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,HUMANA,HUMANA COMMERCIAL, 837.90,,OUTPCT LIMIT, 421.89,OTHER, 18.42, 837.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11198,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,HUMANA,HUMANA COMMERCIAL, 4.70,,OUTPCT LIMIT, 3.08,OTHER, 2.06, 4.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11199,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,HUMANA,HUMANA COMMERCIAL, 341.04,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11200,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,HUMANA,HUMANA COMMERCIAL, 341.04,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11201,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,HUMANA,HUMANA COMMERCIAL, 341.04,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11202,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,HUMANA,HUMANA COMMERCIAL, 341.04,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11203,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,HUMANA,HUMANA COMMERCIAL, 341.04,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11204,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,HUMANA,HUMANA COMMERCIAL, 341.04,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11205,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,HUMANA,HUMANA COMMERCIAL, 341.04,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11206,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,HUMANA,HUMANA COMMERCIAL, 341.04,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11207,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,HUMANA,HUMANA COMMERCIAL, 341.04,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11208,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,HUMANA,HUMANA COMMERCIAL, 341.04,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11209,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,HUMANA,HUMANA COMMERCIAL, 341.04,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11210,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,HUMANA,HUMANA COMMERCIAL, 341.04,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11211,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,HUMANA,HUMANA COMMERCIAL, 406.70,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11212,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,HUMANA,HUMANA COMMERCIAL, 406.70,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11213,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,HUMANA,HUMANA COMMERCIAL, 406.70,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11214,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,HUMANA,HUMANA COMMERCIAL, 406.70,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11215,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11216,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11217,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11218,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11219,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11220,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11221,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11222,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11223,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11224,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11225,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11226,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11227,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11228,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11229,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11230,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11231,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11232,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11233,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11234,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,HUMANA,HUMANA COMMERCIAL, 1299.48,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11235,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,HUMANA,HUMANA COMMERCIAL, 104.13,,OUTPCT LIMIT, 62.01,OTHER, 42.53, 104.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11236,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,HUMANA,HUMANA COMMERCIAL, 111.72,,OUTPCT LIMIT, 73.06,OTHER, 49.02, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11237,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,HUMANA,HUMANA COMMERCIAL, 98.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11238,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,HUMANA,HUMANA COMMERCIAL, 490.00,,OUTPCT LIMIT, 320.46,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11239,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,HUMANA,HUMANA COMMERCIAL, 41.16,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11240,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,HUMANA,HUMANA COMMERCIAL, 2.94,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11241,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,HUMANA,HUMANA COMMERCIAL, 34.30,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11242,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,HUMANA,HUMANA COMMERCIAL, 2.94,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11243,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,HUMANA,HUMANA COMMERCIAL, 26.46,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11244,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,HUMANA,HUMANA COMMERCIAL, 2.94,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11245,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,HUMANA,HUMANA COMMERCIAL, 14.70,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11246,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,HUMANA,HUMANA COMMERCIAL, 3.09,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11247,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,HUMANA,HUMANA COMMERCIAL, 73.50,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11248,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,HUMANA,HUMANA COMMERCIAL, 3.09,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11249,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,HUMANA,HUMANA COMMERCIAL, 4.43,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11250,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,HUMANA,HUMANA COMMERCIAL, 98.98,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11251,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,HUMANA,HUMANA COMMERCIAL, 5.88,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11252,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,HUMANA,HUMANA COMMERCIAL, 5.88,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11253,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,HUMANA,HUMANA COMMERCIAL, 180.24,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11254,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,HUMANA,HUMANA COMMERCIAL, 5.88,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11255,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,HUMANA,HUMANA COMMERCIAL, 176.40,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11256,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,HUMANA,HUMANA COMMERCIAL, 56.84,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11257,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,HUMANA,HUMANA COMMERCIAL, 56.84,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11258,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,HUMANA,HUMANA COMMERCIAL, 325.52,,OUTPCT LIMIT, 212.89,OTHER, 142.83, 325.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11259,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,HUMANA,HUMANA COMMERCIAL, 119.35,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11260,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,HUMANA,HUMANA COMMERCIAL, 73.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11261,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,HUMANA,HUMANA COMMERCIAL, 964.94,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11262,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,HUMANA,HUMANA COMMERCIAL, 702.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11263,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,HUMANA,HUMANA COMMERCIAL, 8.82,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11264,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,HUMANA,HUMANA COMMERCIAL, 5.88,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11265,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,HUMANA,HUMANA COMMERCIAL, 98.98,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11266,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,HUMANA,HUMANA COMMERCIAL, 98.98,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11267,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,HUMANA,HUMANA COMMERCIAL, 98.98,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11268,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,HUMANA,HUMANA COMMERCIAL, 98.98,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11269,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,HUMANA,HUMANA COMMERCIAL, 98.98,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11270,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,HUMANA,HUMANA COMMERCIAL, 98.98,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11271,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,HUMANA,HUMANA COMMERCIAL, 98.98,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11272,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,HUMANA,HUMANA COMMERCIAL, 5.88,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11273,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,HUMANA,HUMANA COMMERCIAL, 98.98,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11274,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,HUMANA,HUMANA COMMERCIAL, 99.96,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11275,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,HUMANA,HUMANA COMMERCIAL, 70.40,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11276,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,HUMANA,HUMANA COMMERCIAL, 70.40,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11277,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,HUMANA,HUMANA COMMERCIAL, 73.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11278,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,HUMANA,HUMANA COMMERCIAL, 134.83,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11279,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,HUMANA,HUMANA COMMERCIAL, 2.94,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11280,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,HUMANA,HUMANA COMMERCIAL, 14.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11281,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,HUMANA,HUMANA COMMERCIAL, 14.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11282,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,HUMANA,HUMANA COMMERCIAL, 14.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11283,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,HUMANA,HUMANA COMMERCIAL, 17.64,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11284,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,HUMANA,HUMANA COMMERCIAL, 23.52,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11285,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,HUMANA,HUMANA COMMERCIAL, 2.94,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11286,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,HUMANA,HUMANA COMMERCIAL, 27.95,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11287,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,HUMANA,HUMANA COMMERCIAL, 27.95,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11288,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,HUMANA,HUMANA COMMERCIAL, 29.40,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11289,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,HUMANA,HUMANA COMMERCIAL, 29.40,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11290,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,HUMANA,HUMANA COMMERCIAL, 29.40,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11291,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,HUMANA,HUMANA COMMERCIAL, 29.40,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11292,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,HUMANA,HUMANA COMMERCIAL, 2.94,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11293,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,HUMANA,HUMANA COMMERCIAL, 2.93,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11294,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,HUMANA,HUMANA COMMERCIAL, 45.56,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11295,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,HUMANA,HUMANA COMMERCIAL, 9.80,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11296,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,HUMANA,HUMANA COMMERCIAL, 3.09,,OUTPCT LIMIT, 2.02,OTHER, 1.35, 3.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11297,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,HUMANA,HUMANA COMMERCIAL, 490.98,,OUTPCT LIMIT, 321.10,OTHER, 215.43, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11298,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,HUMANA,HUMANA COMMERCIAL, 560.56,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11299,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11300,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11301,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11302,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11303,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11304,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11305,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11306,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,HUMANA,HUMANA COMMERCIAL, 33.35,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11307,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,HUMANA,HUMANA COMMERCIAL, 149.15,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11308,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,HUMANA,HUMANA COMMERCIAL, 139.79,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11309,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,HUMANA,HUMANA COMMERCIAL, 91.33,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11310,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,HUMANA,HUMANA COMMERCIAL, 83.83,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11311,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,HUMANA,HUMANA COMMERCIAL, 255.08,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11312,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,HUMANA,HUMANA COMMERCIAL, 7453.59,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11313,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,HUMANA,HUMANA COMMERCIAL, 44.32,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11314,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,HUMANA,HUMANA COMMERCIAL, 1744.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11315,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,HUMANA,HUMANA COMMERCIAL, 1744.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11316,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,HUMANA,HUMANA COMMERCIAL, 1744.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11317,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,HUMANA,HUMANA COMMERCIAL, 1744.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11318,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,HUMANA,HUMANA COMMERCIAL, 1744.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11319,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,HUMANA,HUMANA COMMERCIAL, 1744.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11320,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,HUMANA,HUMANA COMMERCIAL, 2352.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11321,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,HUMANA,HUMANA COMMERCIAL, 1744.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11322,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,HUMANA,HUMANA COMMERCIAL, 1744.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11323,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,HUMANA,HUMANA COMMERCIAL, 1744.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11324,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,HUMANA,HUMANA COMMERCIAL, 1744.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11325,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,HUMANA,HUMANA COMMERCIAL, 1744.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11326,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,HUMANA,HUMANA COMMERCIAL, 1744.40,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11327,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,HUMANA,HUMANA COMMERCIAL, 1372.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11328,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,HUMANA,HUMANA COMMERCIAL, 1372.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11329,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,HUMANA,HUMANA COMMERCIAL, 1372.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11330,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11331,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11332,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11333,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,HUMANA,HUMANA COMMERCIAL, 102.90,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11334,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11335,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,HUMANA,HUMANA COMMERCIAL, 65.79,,OUTPCT LIMIT, 43.03,OTHER, 28.87, 65.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11336,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,HUMANA,HUMANA COMMERCIAL, 9.80,,OUTPCT LIMIT, 6.41,OTHER, 4.30, 9.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11337,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,HUMANA,HUMANA COMMERCIAL, 5684.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11338,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,HUMANA,HUMANA COMMERCIAL, 4704.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11339,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,HUMANA,HUMANA COMMERCIAL, 4704.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11340,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,HUMANA,HUMANA COMMERCIAL, 4704.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11341,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11342,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11343,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,HUMANA,HUMANA COMMERCIAL, 427.28,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11344,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,HUMANA,HUMANA COMMERCIAL, 288.34,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11345,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,HUMANA,HUMANA COMMERCIAL, 297.24,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11346,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,HUMANA,HUMANA COMMERCIAL, 242.17,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11347,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,HUMANA,HUMANA COMMERCIAL, 269.06,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11348,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,HUMANA,HUMANA COMMERCIAL, 555.66,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11349,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,HUMANA,HUMANA COMMERCIAL, 169.93,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11350,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,HUMANA,HUMANA COMMERCIAL, 98.98,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11351,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,HUMANA,HUMANA COMMERCIAL, 99.63,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11352,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,HUMANA,HUMANA COMMERCIAL, 145.78,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11353,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,HUMANA,HUMANA COMMERCIAL, 16.66,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11354,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,HUMANA,HUMANA COMMERCIAL, 27.44,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11355,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11356,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11357,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11358,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11359,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11360,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11361,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11362,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11363,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11364,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11365,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11366,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11367,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,HUMANA,HUMANA COMMERCIAL, 318.50,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11368,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,HUMANA,HUMANA COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 11369,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11370,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11371,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11372,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11373,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11374,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11375,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11376,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11377,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11378,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11379,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11380,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11381,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11382,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11383,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11384,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11385,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11386,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11387,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 209.32,,OUTPAT REV HCPCS COMBO 1, 271.70,OTHER, 142.76, 477.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11388,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 209.32,,OUTPAT REV HCPCS COMBO 1, 271.70,OTHER, 142.76, 477.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11389,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 118.79,,OUTPAT REV HCPCS COMBO 1, 168.89,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11390,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11391,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 211.23,,OUTPAT REV HCPCS COMBO 1, 273.87,OTHER, 142.76, 481.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11392,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11393,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 155.70,,OUTPAT REV HCPCS COMBO 1, 242.16,OTHER, 155.70, 354.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11394,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11395,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11396,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11397,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11398,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11399,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11400,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11401,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11402,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11403,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11404,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11405,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11406,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11407,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11408,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11409,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11410,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11411,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11412,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11413,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11414,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11415,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11416,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11417,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11418,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11419,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11420,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11421,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11422,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11423,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11424,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11425,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11426,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11427,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11428,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11429,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11430,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11431,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11432,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11433,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11434,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11435,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11436,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11437,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 145.30,,OUTPAT REV HCPCS COMBO 1, 185.53,OTHER, 86.20, 331.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11438,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11439,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11440,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11441,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11442,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11443,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11444,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 165.01,,OUTPAT REV HCPCS COMBO 1, 278.63,OTHER, 165.01, 383.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11445,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 296.20,,OUTPAT REV HCPCS COMBO 1, 427.61,OTHER, 296.20, 675.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11446,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 179.25,,OUTPAT REV HCPCS COMBO 1, 237.66,OTHER, 143.26, 408.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11447,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 193.33,,OUTPAT REV HCPCS COMBO 1, 253.66,OTHER, 143.26, 440.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11448,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 209.63,,OUTPAT REV HCPCS COMBO 1, 272.17,OTHER, 143.26, 477.75,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11449,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 191.34,,OUTPAT REV HCPCS COMBO 1, 251.39,OTHER, 143.26, 436.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11450,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11451,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 202.93,,OUTPAT REV HCPCS COMBO 1, 264.56,OTHER, 143.26, 462.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11452,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 204.98,,OUTPAT REV HCPCS COMBO 1, 306.35,OTHER, 204.98, 467.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11453,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11454,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11455,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 230.23,,OUTPAT REV HCPCS COMBO 1, 293.08,OTHER, 132.82, 524.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11456,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 836.72,,OUTPAT REV HCPCS COMBO 1, 1023.77,OTHER, 309.01, 1906.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11457,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11458,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1408.79,,OUTPAT REV HCPCS COMBO 1, 1703.49,OTHER, 435.32, 3210.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11459,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11460,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11461,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11462,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11463,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 145.30,,OUTPAT REV HCPCS COMBO 1, 200.99,OTHER, 145.30, 331.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11464,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11465,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11466,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11467,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11468,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11469,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11470,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11471,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 57.02,,OUTPAT REV HCPCS COMBO 1, 124.43,OTHER, 57.02, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11472,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 53.32,,OUTPAT REV HCPCS COMBO 1, 120.23,OTHER, 53.32, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11473,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 62.14,,OUTPAT REV HCPCS COMBO 1, 130.25,OTHER, 62.14, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11474,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 62.14,,OUTPAT REV HCPCS COMBO 1, 130.25,OTHER, 62.14, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11475,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11476,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11477,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 339.79,,OUTPAT REV HCPCS COMBO 1, 424.57,OTHER, 162.56, 774.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11478,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 260.82,,OUTPAT REV HCPCS COMBO 1, 334.89,OTHER, 162.56, 594.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11479,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 496.58,,OUTPAT REV HCPCS COMBO 1, 675.88,OTHER, 470.23, 1131.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11480,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 406.01,,OUTPAT REV HCPCS COMBO 1, 499.77,OTHER, 162.56, 925.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11481,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 406.01,,OUTPAT REV HCPCS COMBO 1, 499.77,OTHER, 162.56, 925.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11482,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 148.80,,OUTPAT REV HCPCS COMBO 1, 207.69,OTHER, 148.80, 339.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11483,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 148.80,,OUTPAT REV HCPCS COMBO 1, 207.69,OTHER, 148.80, 339.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11484,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 133.93,,OUTPAT REV HCPCS COMBO 1, 176.70,OTHER, 103.34, 305.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11485,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 485.88,,OUTPAT REV HCPCS COMBO 1, 596.69,OTHER, 188.66, 1107.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11486,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 485.88,,OUTPAT REV HCPCS COMBO 1, 596.69,OTHER, 188.66, 1107.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11487,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 845.35,,OUTPAT REV HCPCS COMBO 1, 1089.64,OTHER, 544.52, 1926.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11488,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 15.05,,OUTPAT REV HCPCS COMBO 1, 22.43,OTHER, 15.05, 34.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11489,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11490,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11491,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11492,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11493,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11494,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11495,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 16.02,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11496,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 440.37,,OUTPAT REV HCPCS COMBO 1, 579.04,OTHER, 331.58, 1003.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11497,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11498,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11499,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11500,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11501,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11502,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 124.21,OTHER, 26.22, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11503,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 124.21,OTHER, 26.22, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11504,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11505,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11506,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11507,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11508,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11509,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11510,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11511,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11512,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11513,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11514,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11515,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11516,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 501.48,,OUTPAT REV HCPCS COMBO 1, 718.33,OTHER, 501.48, 1142.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11517,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11518,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11519,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11520,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11521,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11522,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11523,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11524,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11525,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11526,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11527,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11528,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11529,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11530,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11531,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11532,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11533,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11534,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11535,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11536,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11537,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11538,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11539,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11540,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11541,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11542,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 173.27,,OUTPAT REV HCPCS COMBO 1, 242.39,OTHER, 173.27, 394.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11543,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 173.27,,OUTPAT REV HCPCS COMBO 1, 242.39,OTHER, 173.27, 394.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11544,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11545,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 96.75,,OUTPAT REV HCPCS COMBO 1, 199.77,OTHER, 96.75, 377.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11546,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 96.75,,OUTPAT REV HCPCS COMBO 1, 266.50,OTHER, 96.75, 657.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11547,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1478.34,,OUTPAT REV HCPCS COMBO 1, 2146.91,OTHER, 1478.34, 3369.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11548,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1478.34,,OUTPAT REV HCPCS COMBO 1, 2146.91,OTHER, 1478.34, 3369.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11549,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 482.83,,OUTPAT REV HCPCS COMBO 1, 719.65,OTHER, 482.83, 1100.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11550,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 863.68,,OUTPAT REV HCPCS COMBO 1, 1287.31,OTHER, 863.68, 1968.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11551,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 195.18,,OUTPAT REV HCPCS COMBO 1, 290.91,OTHER, 195.18, 444.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11552,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11553,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 112.28,,OUTPAT REV HCPCS COMBO 1, 162.43,OTHER, 112.28, 255.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11554,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 97.21,,OUTPAT REV HCPCS COMBO 1, 145.32,OTHER, 97.21, 221.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11555,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 62.09,,OUTPAT REV HCPCS COMBO 1, 116.13,OTHER, 62.09, 191.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11556,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 76.24,OTHER, 51.17, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11557,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 91.62,,OUTPAT REV HCPCS COMBO 1, 124.60,OTHER, 86.34, 208.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11558,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11559,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11560,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11561,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 58.91,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11562,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11563,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 161.46,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11564,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11565,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11566,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11567,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 122.45,,OUTPAT REV HCPCS COMBO 1, 171.96,OTHER, 122.45, 279.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11568,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11569,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 94.39,,OUTPAT REV HCPCS COMBO 1, 127.74,OTHER, 86.34, 215.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11570,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11571,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 137.97,,OUTPAT REV HCPCS COMBO 1, 189.58,OTHER, 137.97, 314.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11572,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11573,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 84.85,,OUTPAT REV HCPCS COMBO 1, 116.92,OTHER, 84.85, 193.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11574,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11575,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 234.79,,OUTPAT REV HCPCS COMBO 1, 299.54,OTHER, 138.19, 535.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11576,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11577,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 165.67,,OUTPAT REV HCPCS COMBO 1, 221.04,OTHER, 138.19, 377.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11578,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11579,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 127.28,,OUTPAT REV HCPCS COMBO 1, 177.44,OTHER, 127.28, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11580,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11581,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 44.60,,OUTPAT REV HCPCS COMBO 1, 71.21,OTHER, 44.60, 101.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11582,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11583,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 152.34,,OUTPAT REV HCPCS COMBO 1, 193.56,OTHER, 86.34, 347.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11584,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11585,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 178.71,,OUTPAT REV HCPCS COMBO 1, 223.50,OTHER, 86.34, 407.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11586,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1259.10,,OUTPAT REV HCPCS COMBO 1, 1313.91,OTHER, 283.82, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11587,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 935.89,,OUTPAT REV HCPCS COMBO 1, 1313.91,OTHER, 283.82, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11588,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11589,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11590,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 962.60,,OUTPAT REV HCPCS COMBO 1, 1196.04,OTHER, 432.18, 2193.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11591,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 962.60,,OUTPAT REV HCPCS COMBO 1, 1196.04,OTHER, 432.18, 2193.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11592,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11593,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11594,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1259.10,,OUTPAT REV HCPCS COMBO 1, 1545.39,OTHER, 485.27, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11595,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1259.10,,OUTPAT REV HCPCS COMBO 1, 1545.39,OTHER, 485.27, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11596,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11597,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11598,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 781.62,,OUTPAT REV HCPCS COMBO 1, 955.20,OTHER, 283.82, 1781.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11599,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11600,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 518.18,,OUTPAT REV HCPCS COMBO 1, 691.35,OTHER, 432.18, 1180.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11601,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11602,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 679.40,,OUTPAT REV HCPCS COMBO 1, 887.08,OTHER, 485.27, 1548.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11603,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11604,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 734.01,,OUTPAT REV HCPCS COMBO 1, 901.22,OTHER, 283.82, 1673.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11605,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 734.17,,OUTPAT REV HCPCS COMBO 1, 901.22,OTHER, 283.82, 1673.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11606,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11607,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11608,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 839.22,,OUTPAT REV HCPCS COMBO 1, 1055.93,OTHER, 432.18, 1912.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11609,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1056.51,,OUTPAT REV HCPCS COMBO 1, 1302.68,OTHER, 432.18, 2407.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11610,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11611,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11612,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 350.02,,OUTPAT REV HCPCS COMBO 1, 513.03,OTHER, 350.02, 797.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11613,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11614,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1076.96,,OUTPAT REV HCPCS COMBO 1, 1290.59,OTHER, 283.82, 2454.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11615,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11616,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1120.02,,OUTPAT REV HCPCS COMBO 1, 1374.81,OTHER, 432.18, 2552.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11617,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11618,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1013.04,,OUTPAT REV HCPCS COMBO 1, 1265.96,OTHER, 485.27, 2308.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11619,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11620,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 843.77,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11621,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 843.77,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11622,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 843.77,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11623,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11624,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11625,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11626,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1015.19,,OUTPAT REV HCPCS COMBO 1, 1270.81,OTHER, 495.38, 2313.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11627,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11628,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1317.38,,OUTPAT REV HCPCS COMBO 1, 1681.52,OTHER, 779.04, 3002.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11629,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11630,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 971.97,,OUTPAT REV HCPCS COMBO 1, 1224.87,OTHER, 508.57, 2215.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11631,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11632,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1036.73,,OUTPAT REV HCPCS COMBO 1, 1324.21,OTHER, 616.91, 2362.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11633,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11634,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1186.59,,OUTPAT REV HCPCS COMBO 1, 1532.99,OTHER, 779.04, 2704.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11635,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11636,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 979.65,,OUTPAT REV HCPCS COMBO 1, 1233.59,OTHER, 508.57, 2232.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11637,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11638,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 976.96,,OUTPAT REV HCPCS COMBO 1, 1256.33,OTHER, 616.91, 2226.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11639,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11640,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1123.27,,OUTPAT REV HCPCS COMBO 1, 1461.09,OTHER, 779.04, 2560.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11641,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11642,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1138.21,,OUTPAT REV HCPCS COMBO 1, 1413.66,OTHER, 508.57, 2594.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11643,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11644,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1757.38,,OUTPAT REV HCPCS COMBO 1, 2181.19,OTHER, 779.04, 4005.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11645,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1757.38,,OUTPAT REV HCPCS COMBO 1, 2181.19,OTHER, 779.04, 4005.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11646,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11647,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11648,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11649,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11650,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11651,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11652,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11653,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11654,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11655,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11656,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11657,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11658,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11659,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11660,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11661,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11662,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 195.04,,OUTPAT REV HCPCS COMBO 1, 242.05,OTHER, 86.34, 444.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11663,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 196.33,,OUTPAT REV HCPCS COMBO 1, 243.52,OTHER, 86.34, 447.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11664,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11665,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11666,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 159.59,,OUTPAT REV HCPCS COMBO 1, 214.14,OTHER, 138.19, 363.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11667,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 182.39,,OUTPAT REV HCPCS COMBO 1, 240.03,OTHER, 138.19, 415.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11668,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11669,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11670,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 190.18,,OUTPAT REV HCPCS COMBO 1, 248.87,OTHER, 138.19, 433.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11671,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11672,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 127.28,,OUTPAT REV HCPCS COMBO 1, 165.10,OTHER, 86.34, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11673,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11674,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11675,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11676,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11677,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11678,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11679,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11680,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11681,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1356.87,OTHER, 432.18, 2737.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11682,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1201.21,,OUTPAT REV HCPCS COMBO 1, 1356.87,OTHER, 432.18, 2737.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11683,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11684,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1498.49,,OUTPAT REV HCPCS COMBO 1, 1817.25,OTHER, 485.27, 3415.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11685,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11686,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11687,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11688,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11689,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11690,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11691,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11692,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2141.41,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11693,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11694,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11695,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11696,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11697,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11698,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11699,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11700,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11701,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 544.38,,OUTPAT REV HCPCS COMBO 1, 1310.99,OTHER, 544.38, 2768.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11702,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1214.75,,OUTPAT REV HCPCS COMBO 1, 1310.99,OTHER, 544.38, 2768.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11703,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11704,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11705,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 130.72,,OUTPAT REV HCPCS COMBO 1, 169.01,OTHER, 86.34, 297.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11706,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 130.72,,OUTPAT REV HCPCS COMBO 1, 169.01,OTHER, 86.34, 297.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11707,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11708,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11709,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 189.11,,OUTPAT REV HCPCS COMBO 1, 247.65,OTHER, 138.19, 430.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11710,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11711,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 279.76,,OUTPAT REV HCPCS COMBO 1, 350.60,OTHER, 138.19, 637.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11712,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11713,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 307.96,,OUTPAT REV HCPCS COMBO 1, 382.63,OTHER, 138.19, 701.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11714,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11715,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 229.47,,OUTPAT REV HCPCS COMBO 1, 293.50,OTHER, 138.19, 522.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11716,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11717,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 205.14,,OUTPAT REV HCPCS COMBO 1, 265.86,OTHER, 138.19, 467.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11718,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11719,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 161.46,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11720,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11721,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 107.50,,OUTPAT REV HCPCS COMBO 1, 142.64,OTHER, 86.34, 245.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11722,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11723,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.06,OTHER, 36.98, 88.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11724,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 163.44,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11725,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11726,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 199.31,,OUTPAT REV HCPCS COMBO 1, 259.24,OTHER, 138.19, 454.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11727,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11728,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 118.00,,OUTPAT REV HCPCS COMBO 1, 166.91,OTHER, 118.00, 268.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11729,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11730,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 329.50,,OUTPAT REV HCPCS COMBO 1, 407.08,OTHER, 138.19, 750.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11731,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11732,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1225.59,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11733,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1225.59,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11734,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1225.59,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11735,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11736,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11737,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11738,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 483.75,,OUTPAT REV HCPCS COMBO 1, 664.89,OTHER, 483.75, 1102.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11739,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11740,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1392.67,,OUTPAT REV HCPCS COMBO 1, 1649.11,OTHER, 283.82, 3173.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11741,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1392.67,,OUTPAT REV HCPCS COMBO 1, 1649.11,OTHER, 283.82, 3173.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11742,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11743,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11744,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1376.00,,OUTPAT REV HCPCS COMBO 1, 1665.51,OTHER, 432.18, 3136.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11745,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11746,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1207.81,,OUTPAT REV HCPCS COMBO 1, 1439.18,OTHER, 283.82, 2752.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11747,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11748,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1364.62,,OUTPAT REV HCPCS COMBO 1, 1652.58,OTHER, 432.18, 3110.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11749,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11750,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1290.00,,OUTPAT REV HCPCS COMBO 1, 1580.48,OTHER, 485.27, 2940.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11751,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11752,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1401.19,,OUTPAT REV HCPCS COMBO 1, 1712.29,OTHER, 508.57, 3193.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11753,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11754,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1561.88,,OUTPAT REV HCPCS COMBO 1, 1894.78,OTHER, 508.57, 3559.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11755,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11756,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1370.93,,OUTPAT REV HCPCS COMBO 1, 1677.93,OTHER, 508.57, 3124.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11757,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11758,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1703.32,,OUTPAT REV HCPCS COMBO 1, 2119.80,OTHER, 779.04, 3881.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11759,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11760,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2072.93,,OUTPAT REV HCPCS COMBO 1, 2539.54,OTHER, 779.04, 4724.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11761,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11762,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1941.42,,OUTPAT REV HCPCS COMBO 1, 2390.20,OTHER, 779.04, 4424.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11763,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11764,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11765,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11766,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11767,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 179.56,,OUTPAT REV HCPCS COMBO 1, 236.81,OTHER, 138.19, 409.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11768,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11769,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 141.74,,OUTPAT REV HCPCS COMBO 1, 193.87,OTHER, 138.19, 323.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11770,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11771,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1051.04,,OUTPAT REV HCPCS COMBO 1, 1261.16,OTHER, 283.82, 2395.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11772,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1051.04,,OUTPAT REV HCPCS COMBO 1, 1261.16,OTHER, 283.82, 2395.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11773,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11774,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11775,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1015.49,,OUTPAT REV HCPCS COMBO 1, 1256.10,OTHER, 432.18, 2314.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11776,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11777,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 686.07,,OUTPAT REV HCPCS COMBO 1, 894.65,OTHER, 485.27, 1563.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11778,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11779,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1435.73,,OUTPAT REV HCPCS COMBO 1, 1751.53,OTHER, 508.57, 3272.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11780,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11781,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2152.02,,OUTPAT REV HCPCS COMBO 1, 2629.35,OTHER, 779.04, 4904.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11782,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11783,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11784,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11785,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11786,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11787,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11788,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11789,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 126.48,,OUTPAT REV HCPCS COMBO 1, 164.19,OTHER, 86.34, 288.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11790,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11791,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 179.46,,OUTPAT REV HCPCS COMBO 1, 224.35,OTHER, 86.34, 408.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11792,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11793,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 165.68,,OUTPAT REV HCPCS COMBO 1, 208.71,OTHER, 86.34, 377.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11794,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 165.68,,OUTPAT REV HCPCS COMBO 1, 208.71,OTHER, 86.34, 377.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11795,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 171.85,,OUTPAT REV HCPCS COMBO 1, 215.71,OTHER, 86.34, 391.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11796,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11797,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11798,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11799,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11800,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11801,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11802,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11803,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11804,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11805,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 136.74,,OUTPAT REV HCPCS COMBO 1, 175.84,OTHER, 86.34, 311.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11806,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 130.77,,OUTPAT REV HCPCS COMBO 1, 169.06,OTHER, 86.34, 298.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11807,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 130.77,,OUTPAT REV HCPCS COMBO 1, 169.06,OTHER, 86.34, 298.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11808,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11809,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11810,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11811,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 178.02,,OUTPAT REV HCPCS COMBO 1, 235.06,OTHER, 138.19, 405.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11812,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 178.02,,OUTPAT REV HCPCS COMBO 1, 235.06,OTHER, 138.19, 405.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11813,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 182.68,,OUTPAT REV HCPCS COMBO 1, 240.36,OTHER, 138.19, 416.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11814,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11815,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11816,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11817,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 175.36,,OUTPAT REV HCPCS COMBO 1, 219.70,OTHER, 86.34, 399.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11818,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 170.74,,OUTPAT REV HCPCS COMBO 1, 214.45,OTHER, 86.34, 389.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11819,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 170.74,,OUTPAT REV HCPCS COMBO 1, 214.45,OTHER, 86.34, 389.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11820,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11821,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11822,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11823,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 163.79,,OUTPAT REV HCPCS COMBO 1, 206.56,OTHER, 86.34, 373.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11824,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 168.41,,OUTPAT REV HCPCS COMBO 1, 211.81,OTHER, 86.34, 383.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11825,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 163.79,,OUTPAT REV HCPCS COMBO 1, 206.56,OTHER, 86.34, 373.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11826,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11827,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11828,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11829,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 184.47,,OUTPAT REV HCPCS COMBO 1, 230.04,OTHER, 86.34, 420.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11830,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 178.71,,OUTPAT REV HCPCS COMBO 1, 223.50,OTHER, 86.34, 407.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11831,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11832,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11833,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11834,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 185.16,,OUTPAT REV HCPCS COMBO 1, 230.83,OTHER, 86.34, 421.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11835,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 185.16,,OUTPAT REV HCPCS COMBO 1, 230.83,OTHER, 86.34, 421.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11836,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 190.92,,OUTPAT REV HCPCS COMBO 1, 237.37,OTHER, 86.34, 435.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11837,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11838,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11839,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11840,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 58.91,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11841,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 81.70,,OUTPAT REV HCPCS COMBO 1, 125.68,OTHER, 81.70, 186.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11842,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 58.91,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11843,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11844,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11845,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11846,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 170.11,,OUTPAT REV HCPCS COMBO 1, 213.73,OTHER, 86.34, 387.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11847,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 164.82,,OUTPAT REV HCPCS COMBO 1, 207.73,OTHER, 86.34, 375.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11848,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 164.83,,OUTPAT REV HCPCS COMBO 1, 207.74,OTHER, 86.34, 375.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11849,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11850,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11851,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11852,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 191.64,,OUTPAT REV HCPCS COMBO 1, 238.18,OTHER, 86.34, 436.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11853,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 196.26,,OUTPAT REV HCPCS COMBO 1, 243.44,OTHER, 86.34, 447.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11854,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 191.64,,OUTPAT REV HCPCS COMBO 1, 238.18,OTHER, 86.34, 436.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11855,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11856,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11857,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11858,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 181.03,,OUTPAT REV HCPCS COMBO 1, 238.48,OTHER, 138.19, 412.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11859,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 175.27,,OUTPAT REV HCPCS COMBO 1, 231.94,OTHER, 138.19, 399.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11860,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 175.27,,OUTPAT REV HCPCS COMBO 1, 231.94,OTHER, 138.19, 399.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11861,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11862,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11863,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11864,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 175.94,,OUTPAT REV HCPCS COMBO 1, 220.36,OTHER, 86.34, 400.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11865,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 175.99,,OUTPAT REV HCPCS COMBO 1, 220.42,OTHER, 86.34, 401.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11866,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 180.62,,OUTPAT REV HCPCS COMBO 1, 225.67,OTHER, 86.34, 411.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11867,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11868,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11869,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11870,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 146.59,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11871,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 135.73,,OUTPAT REV HCPCS COMBO 1, 174.69,OTHER, 86.34, 309.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11872,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11873,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11874,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11875,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11876,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11877,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11878,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11879,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11880,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11881,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11882,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11883,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11884,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11885,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11886,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11887,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11888,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11889,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11890,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11891,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11892,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11893,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11894,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11895,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11896,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 813.42,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11897,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 1061.06,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11898,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11899,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11900,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11901,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11902,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11903,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 287.67,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11904,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 287.67,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11905,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11906,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11907,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 287.67,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11908,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11909,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11910,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 813.42,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11911,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11912,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11913,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11914,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11915,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11916,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11917,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11918,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11919,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11920,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11921,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11922,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11923,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11924,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11925,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1216.47,,OUTPAT REV HCPCS COMBO 1, 1484.34,OTHER, 432.18, 2772.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11926,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1216.47,,OUTPAT REV HCPCS COMBO 1, 1484.34,OTHER, 432.18, 2772.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11927,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11928,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11929,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11930,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11931,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11932,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11933,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11934,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 822.87,,OUTPAT REV HCPCS COMBO 1, 1055.55,OTHER, 508.57, 1875.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11935,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11936,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1419.11,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11937,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1419.11,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11938,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1419.11,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11939,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11940,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11941,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11942,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11943,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11944,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11945,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11946,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11947,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11948,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11949,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11950,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11951,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11952,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11953,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11954,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11955,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11956,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11957,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11958,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11959,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11960,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11961,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11962,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11963,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11964,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11965,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11966,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11967,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11968,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11969,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11970,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11971,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11972,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11973,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11974,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1113.81,,OUTPAT REV HCPCS COMBO 1, 1450.34,OTHER, 779.04, 2538.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11975,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1113.81,,OUTPAT REV HCPCS COMBO 1, 1450.34,OTHER, 779.04, 2538.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11976,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11977,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11978,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11979,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11980,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11981,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11982,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 154.92,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11983,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 154.92,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11984,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 154.92,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11985,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11986,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11987,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11988,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11989,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11990,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11991,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11992,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11993,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11994,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11995,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11996,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 11997,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 195.73,,OUTPAT REV HCPCS COMBO 1, 234.40,OTHER, 146.51, 446.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11998,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 155.65,,OUTPAT REV HCPCS COMBO 1, 234.40,OTHER, 146.51, 446.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 11999,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12000,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12001,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 160.19,,OUTPAT REV HCPCS COMBO 1, 202.98,OTHER, 88.46, 365.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12002,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 160.19,,OUTPAT REV HCPCS COMBO 1, 202.98,OTHER, 88.46, 365.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12003,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 164.81,,OUTPAT REV HCPCS COMBO 1, 208.23,OTHER, 88.46, 375.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12004,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12005,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12006,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12007,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 167.46,,OUTPAT REV HCPCS COMBO 1, 210.73,OTHER, 86.34, 381.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12008,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 162.18,,OUTPAT REV HCPCS COMBO 1, 204.73,OTHER, 86.34, 369.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12009,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 162.18,,OUTPAT REV HCPCS COMBO 1, 204.73,OTHER, 86.34, 369.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12010,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12011,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12012,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12013,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 208.05,,OUTPAT REV HCPCS COMBO 1, 269.16,OTHER, 138.19, 474.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12014,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 212.67,,OUTPAT REV HCPCS COMBO 1, 274.41,OTHER, 138.19, 484.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12015,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 208.05,,OUTPAT REV HCPCS COMBO 1, 269.16,OTHER, 138.19, 474.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12016,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12017,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12018,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12019,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 325.08,,OUTPAT REV HCPCS COMBO 1, 402.07,OTHER, 138.19, 740.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12020,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 319.17,,OUTPAT REV HCPCS COMBO 1, 395.36,OTHER, 138.19, 727.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12021,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 319.17,,OUTPAT REV HCPCS COMBO 1, 395.36,OTHER, 138.19, 727.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12022,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12023,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12024,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12025,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 116.95,,OUTPAT REV HCPCS COMBO 1, 153.37,OTHER, 86.34, 266.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12026,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12027,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 195.94,,OUTPAT REV HCPCS COMBO 1, 243.07,OTHER, 86.34, 446.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12028,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 191.32,,OUTPAT REV HCPCS COMBO 1, 237.82,OTHER, 86.34, 436.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12029,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 191.32,,OUTPAT REV HCPCS COMBO 1, 237.82,OTHER, 86.34, 436.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12030,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12031,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12032,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12033,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 74.90,OTHER, 36.98, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12034,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 74.90,OTHER, 36.98, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12035,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 73.96,,OUTPAT REV HCPCS COMBO 1, 116.89,OTHER, 73.96, 168.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12036,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12037,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12038,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12039,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 163.83,,OUTPAT REV HCPCS COMBO 1, 218.95,OTHER, 138.19, 373.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12040,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 163.83,,OUTPAT REV HCPCS COMBO 1, 218.95,OTHER, 138.19, 373.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12041,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 169.42,,OUTPAT REV HCPCS COMBO 1, 225.30,OTHER, 138.19, 386.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12042,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12043,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12044,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12045,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 185.33,,OUTPAT REV HCPCS COMBO 1, 243.37,OTHER, 138.19, 422.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12046,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 179.52,,OUTPAT REV HCPCS COMBO 1, 236.76,OTHER, 138.19, 409.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12047,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 179.52,,OUTPAT REV HCPCS COMBO 1, 236.76,OTHER, 138.19, 409.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12048,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12049,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12050,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12051,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 146.18,,OUTPAT REV HCPCS COMBO 1, 186.56,OTHER, 86.34, 333.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12052,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 146.18,,OUTPAT REV HCPCS COMBO 1, 186.56,OTHER, 86.34, 333.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12053,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12054,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12055,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 202.21,,OUTPAT REV HCPCS COMBO 1, 250.19,OTHER, 86.34, 460.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12056,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 197.50,,OUTPAT REV HCPCS COMBO 1, 244.84,OTHER, 86.34, 450.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12057,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 197.59,,OUTPAT REV HCPCS COMBO 1, 244.94,OTHER, 86.34, 450.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12058,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12059,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12060,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12061,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 100.19,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12062,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 100.19,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12063,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 100.19,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12064,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12065,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12066,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12067,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12068,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12069,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12070,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12071,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12072,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12073,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12074,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12075,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 139.75,,OUTPAT REV HCPCS COMBO 1, 179.26,OTHER, 86.34, 318.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12076,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12077,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12078,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12079,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12080,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12081,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12082,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12083,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12084,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12085,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12086,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12087,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12088,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12089,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12090,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12091,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12092,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 991.15,,OUTPAT REV HCPCS COMBO 1, 1193.14,OTHER, 283.82, 2258.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12093,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12094,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12095,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12096,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12097,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12098,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12099,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12100,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12101,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12102,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12103,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12104,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12105,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12106,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12107,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12108,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12109,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12110,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12111,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12112,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12113,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12114,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12115,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12116,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12117,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1173.04,,OUTPAT REV HCPCS COMBO 1, 1435.02,OTHER, 432.18, 2673.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12118,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1167.20,,OUTPAT REV HCPCS COMBO 1, 1428.39,OTHER, 432.18, 2660.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12119,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1167.20,,OUTPAT REV HCPCS COMBO 1, 1428.39,OTHER, 432.18, 2660.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12120,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12121,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12122,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12123,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12124,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12125,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12126,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12127,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12128,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12129,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 597.27,,OUTPAT REV HCPCS COMBO 1, 796.22,OTHER, 495.38, 1361.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12130,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 597.27,,OUTPAT REV HCPCS COMBO 1, 796.22,OTHER, 495.38, 1361.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12131,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12132,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12133,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12134,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12135,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12136,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12137,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12138,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12139,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12140,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12141,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12142,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12143,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12144,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12145,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1556.76,,OUTPAT REV HCPCS COMBO 1, 1953.37,OTHER, 779.04, 3547.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12146,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1556.76,,OUTPAT REV HCPCS COMBO 1, 1953.37,OTHER, 779.04, 3547.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12147,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12148,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12149,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12150,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12151,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1356.11,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12152,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1356.11,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12153,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12154,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12155,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12156,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12157,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12158,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12159,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12160,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12161,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12162,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12163,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12164,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12165,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12166,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12167,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12168,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12169,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12170,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12171,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12172,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12173,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12174,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12175,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12176,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12177,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12178,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12179,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1227.35,OTHER, 786.90, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12180,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1323.48,OTHER, 786.90, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12181,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1474.10,OTHER, 989.00, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12182,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 786.90,,OUTPAT REV HCPCS COMBO 1, 1227.35,OTHER, 786.90, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12183,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 786.90,,OUTPAT REV HCPCS COMBO 1, 1323.48,OTHER, 786.90, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12184,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12185,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12186,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12187,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12188,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12189,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 71.38,,OUTPAT REV HCPCS COMBO 1, 102.58,OTHER, 71.38, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12190,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 71.38,,OUTPAT REV HCPCS COMBO 1, 102.58,OTHER, 71.38, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12191,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12192,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12193,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 83.13,OTHER, 36.98, 172.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12194,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12195,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 254.96,,OUTPAT REV HCPCS COMBO 1, 322.43,OTHER, 138.19, 581.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12196,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 254.96,,OUTPAT REV HCPCS COMBO 1, 322.43,OTHER, 138.19, 581.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12197,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12198,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12199,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1125.78,,OUTPAT REV HCPCS COMBO 1, 1346.03,OTHER, 283.82, 2565.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12200,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12201,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1269.20,,OUTPAT REV HCPCS COMBO 1, 1544.22,OTHER, 432.18, 2892.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12202,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12203,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1433.28,,OUTPAT REV HCPCS COMBO 1, 1743.20,OTHER, 485.27, 3266.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12204,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12205,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2571.41,,OUTPAT REV HCPCS COMBO 1, 3113.75,OTHER, 813.20, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12206,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12207,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1431.39,,OUTPAT REV HCPCS COMBO 1, 1743.46,OTHER, 495.38, 3262.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12208,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12209,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2239.96,,OUTPAT REV HCPCS COMBO 1, 2609.45,OTHER, 276.02, 5105.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12210,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2239.96,,OUTPAT REV HCPCS COMBO 1, 2609.45,OTHER, 276.02, 5105.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12211,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12212,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12213,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2571.41,,OUTPAT REV HCPCS COMBO 1, 3021.78,OTHER, 426.91, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12214,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2571.41,,OUTPAT REV HCPCS COMBO 1, 3021.78,OTHER, 426.91, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12215,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12216,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12217,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2881.09,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12218,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2881.09,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12219,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2881.09,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12220,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12221,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12222,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12223,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1381.27,,OUTPAT REV HCPCS COMBO 1, 1689.68,OTHER, 508.57, 3148.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12224,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1381.27,,OUTPAT REV HCPCS COMBO 1, 1689.68,OTHER, 508.57, 3148.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12225,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12226,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12227,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1454.34,,OUTPAT REV HCPCS COMBO 1, 1837.06,OTHER, 779.04, 3314.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12228,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12229,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1075.00,,OUTPAT REV HCPCS COMBO 1, 2098.35,OTHER, 1075.00, 3967.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12230,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1740.64,,OUTPAT REV HCPCS COMBO 1, 2098.35,OTHER, 1075.00, 3967.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12231,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12232,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12233,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12234,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 300.14,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12235,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 300.14,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12236,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 300.14,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12237,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12238,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12239,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 472.37,,OUTPAT REV HCPCS COMBO 1, 704.06,OTHER, 472.37, 1076.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12240,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12241,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 166.15,,OUTPAT REV HCPCS COMBO 1, 248.14,OTHER, 166.15, 378.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12242,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12243,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 326.19,,OUTPAT REV HCPCS COMBO 1, 429.88,OTHER, 249.71, 743.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12244,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12245,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1213.11,,OUTPAT REV HCPCS COMBO 1, 1495.57,OTHER, 495.38, 2764.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12246,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1213.11,,OUTPAT REV HCPCS COMBO 1, 1495.57,OTHER, 495.38, 2764.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12247,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12248,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12249,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 150.50,,OUTPAT REV HCPCS COMBO 1, 224.32,OTHER, 150.50, 343.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12250,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12251,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 309.81,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12252,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 309.81,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12253,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 309.81,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12254,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12255,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12256,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12257,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 233.31,,OUTPAT REV HCPCS COMBO 1, 286.59,OTHER, 90.89, 531.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12258,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12259,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 219.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12260,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 219.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12261,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 219.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12262,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 225.75,,OUTPAT REV HCPCS COMBO 1, 288.12,OTHER, 133.37, 514.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12263,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12264,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12265,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12266,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12267,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 413.68,,OUTPAT REV HCPCS COMBO 1, 503.49,OTHER, 141.55, 942.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12268,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12269,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12270,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12271,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12272,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12273,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12274,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12275,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12276,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12277,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12278,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12279,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 468.07,OTHER, 163.97, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12280,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12281,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12282,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12283,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12284,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12285,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 335.33,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12286,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12287,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12288,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12289,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12290,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12291,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 335.33,,OUTPAT REV HCPCS COMBO 1, 414.50,OTHER, 141.55, 764.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12292,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12293,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 161.25,,OUTPAT REV HCPCS COMBO 1, 214.87,OTHER, 133.37, 367.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12294,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12295,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 330.24,,OUTPAT REV HCPCS COMBO 1, 408.73,OTHER, 141.55, 752.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12296,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12297,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 417.26,,OUTPAT REV HCPCS COMBO 1, 507.55,OTHER, 141.55, 950.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12298,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12299,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 663.92,,OUTPAT REV HCPCS COMBO 1, 775.60,OTHER, 90.89, 1513.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12300,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12301,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 227.90,,OUTPAT REV HCPCS COMBO 1, 290.56,OTHER, 133.37, 519.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12302,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12303,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 339.97,,OUTPAT REV HCPCS COMBO 1, 419.77,OTHER, 141.55, 774.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12304,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12305,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 385.59,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12306,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 385.59,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12307,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 385.59,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12308,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12309,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12310,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12311,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 269.07,,OUTPAT REV HCPCS COMBO 1, 322.12,OTHER, 90.89, 613.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12312,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 260.12,,OUTPAT REV HCPCS COMBO 1, 322.12,OTHER, 90.89, 613.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12313,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12314,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12315,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 330.02,,OUTPAT REV HCPCS COMBO 1, 408.48,OTHER, 141.55, 752.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12316,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12317,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 688.00,,OUTPAT REV HCPCS COMBO 1, 813.95,OTHER, 137.10, 1568.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12318,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 435.01,,OUTPAT REV HCPCS COMBO 1, 526.64,OTHER, 137.10, 991.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12319,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 435.01,,OUTPAT REV HCPCS COMBO 1, 526.64,OTHER, 137.10, 991.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12320,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12321,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12322,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12323,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12324,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 236.50,,OUTPAT REV HCPCS COMBO 1, 300.33,OTHER, 133.37, 539.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12325,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12326,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12327,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12328,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12329,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12330,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12331,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12332,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12333,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12334,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12335,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12336,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12337,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12338,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12339,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12340,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12341,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 285.90,,OUTPAT REV HCPCS COMBO 1, 426.14,OTHER, 285.90, 651.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12342,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12343,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 182.57,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12344,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 182.57,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12345,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 182.57,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12346,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12347,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12348,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12349,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12350,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 186.51,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12351,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 186.51,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12352,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 61.06,,OUTPAT REV HCPCS COMBO 1, 91.01,OTHER, 61.06, 139.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12353,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 21.15,,OUTPAT REV HCPCS COMBO 1, 78.82,OTHER, 21.15, 181.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12354,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12355,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12356,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12357,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12358,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12359,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12360,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12361,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12362,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 210.70,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12363,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 175.87,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12364,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 210.70,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12365,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12366,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12367,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12368,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12369,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12370,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12371,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12372,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12373,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12374,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12375,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12376,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12377,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12378,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12379,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12380,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12381,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 73.53,,OUTPAT REV HCPCS COMBO 1, 116.40,OTHER, 73.53, 167.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12382,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12383,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 315.98,,OUTPAT REV HCPCS COMBO 1, 414.07,OTHER, 232.03, 720.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12384,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 84.28,,OUTPAT REV HCPCS COMBO 1, 158.67,OTHER, 84.28, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12385,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 150.93,,OUTPAT REV HCPCS COMBO 1, 158.67,OTHER, 84.28, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12386,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12387,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12388,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 127.28,,OUTPAT REV HCPCS COMBO 1, 154.63,OTHER, 42.36, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12389,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 150.93,,OUTPAT REV HCPCS COMBO 1, 204.30,OTHER, 138.19, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12390,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12391,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 549.04,,OUTPAT REV HCPCS COMBO 1, 660.83,OTHER, 156.82, 1251.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12392,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 549.04,,OUTPAT REV HCPCS COMBO 1, 660.83,OTHER, 156.82, 1251.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12393,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12394,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12395,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 426.80,,OUTPAT REV HCPCS COMBO 1, 533.81,OTHER, 206.35, 972.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12396,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 426.80,,OUTPAT REV HCPCS COMBO 1, 533.81,OTHER, 206.35, 972.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12397,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12398,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12399,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 600.24,,OUTPAT REV HCPCS COMBO 1, 757.92,OTHER, 320.35, 1367.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12400,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12401,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 724.72,,OUTPAT REV HCPCS COMBO 1, 899.81,OTHER, 322.62, 1651.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12402,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12403,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 847.10,,OUTPAT REV HCPCS COMBO 1, 1092.65,OTHER, 548.80, 1930.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12404,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12405,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 672.15,,OUTPAT REV HCPCS COMBO 1, 864.03,OTHER, 423.08, 1531.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12406,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12407,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 215.00,,OUTPAT REV HCPCS COMBO 1, 344.89,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12408,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12409,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 645.00,,OUTPAT REV HCPCS COMBO 1, 830.31,OTHER, 410.92, 1470.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12410,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12411,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 885.80,,OUTPAT REV HCPCS COMBO 1, 1103.77,OTHER, 410.92, 2018.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12412,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12413,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1111.16,OTHER, 359.95, 2058.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12414,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12415,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 474.08,,OUTPAT REV HCPCS COMBO 1, 624.07,OTHER, 359.95, 1080.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12416,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12417,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 516.57,,OUTPAT REV HCPCS COMBO 1, 672.34,OTHER, 360.01, 1177.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12418,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12419,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 417.10,,OUTPAT REV HCPCS COMBO 1, 559.38,OTHER, 360.01, 950.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12420,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12421,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1005.92,,OUTPAT REV HCPCS COMBO 1, 1228.06,OTHER, 360.01, 2292.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12422,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12423,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1064.04,,OUTPAT REV HCPCS COMBO 1, 1294.05,OTHER, 360.01, 2425.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12424,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12425,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 470.85,,OUTPAT REV HCPCS COMBO 1, 701.80,OTHER, 470.85, 1073.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12426,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12427,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 775.51,,OUTPAT REV HCPCS COMBO 1, 1149.19,OTHER, 775.51, 1767.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12428,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 775.51,,OUTPAT REV HCPCS COMBO 1, 1149.19,OTHER, 775.51, 1767.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12429,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12430,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12431,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1760.54,,OUTPAT REV HCPCS COMBO 1, 2267.81,OTHER, 1127.76, 4012.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12432,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12433,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 624.40,,OUTPAT REV HCPCS COMBO 1, 815.01,OTHER, 444.92, 1423.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12434,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 624.40,,OUTPAT REV HCPCS COMBO 1, 815.01,OTHER, 444.92, 1423.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12435,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12436,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12437,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 500.41,,OUTPAT REV HCPCS COMBO 1, 635.79,OTHER, 283.54, 1140.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12438,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12439,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 803.60,,OUTPAT REV HCPCS COMBO 1, 984.09,OTHER, 300.36, 1831.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12440,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12441,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 831.76,,OUTPAT REV HCPCS COMBO 1, 1050.06,OTHER, 443.12, 1895.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12442,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12443,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 447.20,,OUTPAT REV HCPCS COMBO 1, 684.67,OTHER, 447.20, 1019.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12444,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12445,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2048.52,,OUTPAT REV HCPCS COMBO 1, 2685.69,OTHER, 1509.32, 4668.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12446,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12447,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2121.62,,OUTPAT REV HCPCS COMBO 1, 2768.70,OTHER, 1509.32, 4835.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12448,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 12449,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 26.05,,OUTPAT REV HCPCS COMBO 1, 34.30,OTHER, 19.78, 59.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12450,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 26.05,,OUTPAT REV HCPCS COMBO 1, 32.49,OTHER, 12.18, 59.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12451,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 267.46,,OUTPAT REV HCPCS COMBO 1, 398.65,OTHER, 267.46, 609.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12452,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 60.14,,OUTPAT REV HCPCS COMBO 1, 70.69,OTHER, 10.09, 137.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12453,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 104.38,,OUTPAT REV HCPCS COMBO 1, 122.16,OTHER, 15.20, 237.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12454,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 81.90,,OUTPAT REV HCPCS COMBO 1, 97.60,OTHER, 19.28, 186.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12455,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 81.90,,OUTPAT REV HCPCS COMBO 1, 97.60,OTHER, 19.28, 186.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12456,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 70.95,,OUTPAT REV HCPCS COMBO 1, 83.55,OTHER, 12.50, 161.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12457,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 70.95,,OUTPAT REV HCPCS COMBO 1, 83.55,OTHER, 12.50, 161.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12458,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 122.86,,OUTPAT REV HCPCS COMBO 1, 155.85,OTHER, 68.59, 280.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12459,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 67.08,,OUTPAT REV HCPCS COMBO 1, 78.98,OTHER, 11.76, 152.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12460,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 56.33,,OUTPAT REV HCPCS COMBO 1, 69.30,OTHER, 22.37, 128.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12461,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 192.21,,OUTPAT REV HCPCS COMBO 1, 229.30,OTHER, 46.28, 438.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12462,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 75.79,,OUTPAT REV HCPCS COMBO 1, 88.95,OTHER, 20.98, 172.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12463,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 72.07,,OUTPAT REV HCPCS COMBO 1, 88.95,OTHER, 20.98, 172.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12464,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 53.39,OTHER, 19.13, 98.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12465,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 53.39,OTHER, 19.13, 98.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12466,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 66.51,,OUTPAT REV HCPCS COMBO 1, 80.17,OTHER, 19.50, 151.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12467,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 41.55,,OUTPAT REV HCPCS COMBO 1, 54.61,OTHER, 31.20, 94.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12468,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 66.47,,OUTPAT REV HCPCS COMBO 1, 80.03,OTHER, 19.08, 151.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12469,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.72,,OUTPAT REV HCPCS COMBO 1, 79.17,OTHER, 19.08, 149.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12470,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 54.32,,OUTPAT REV HCPCS COMBO 1, 63.95,OTHER, 9.52, 123.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12471,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 20.21,,OUTPAT REV HCPCS COMBO 1, 28.28,OTHER, 20.21, 46.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12472,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 69.69,,OUTPAT REV HCPCS COMBO 1, 83.69,OTHER, 19.08, 158.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12473,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 42.46,,OUTPAT REV HCPCS COMBO 1, 53.47,OTHER, 22.03, 96.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12474,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 66.28,,OUTPAT REV HCPCS COMBO 1, 79.81,OTHER, 19.08, 151.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12475,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 35.17,,OUTPAT REV HCPCS COMBO 1, 44.64,OTHER, 19.78, 80.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12476,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 124.34,,OUTPAT REV HCPCS COMBO 1, 145.91,OTHER, 19.78, 283.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12477,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 52.76,,OUTPAT REV HCPCS COMBO 1, 64.76,OTHER, 20.36, 120.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12478,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 103.25,,OUTPAT REV HCPCS COMBO 1, 121.34,OTHER, 17.16, 235.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12479,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 70.55,,OUTPAT REV HCPCS COMBO 1, 84.76,OTHER, 19.50, 160.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12480,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 111.79,,OUTPAT REV HCPCS COMBO 1, 134.69,OTHER, 32.53, 254.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12481,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 74.42,,OUTPAT REV HCPCS COMBO 1, 90.91,OTHER, 26.84, 169.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12482,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 81.85,,OUTPAT REV HCPCS COMBO 1, 56.90,OTHER, 10.75, 186.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12483,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 56.90,OTHER, 10.75, 186.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12484,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 17.20,,OUTPAT REV HCPCS COMBO 1, 23.85,OTHER, 17.20, 39.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12485,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 17.20,,OUTPAT REV HCPCS COMBO 1, 23.85,OTHER, 17.20, 39.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12486,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 112.61,,OUTPAT REV HCPCS COMBO 1, 178.46,OTHER, 112.61, 289.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12487,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 126.85,,OUTPAT REV HCPCS COMBO 1, 178.46,OTHER, 112.61, 289.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12488,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 72.67,,OUTPAT REV HCPCS COMBO 1, 108.31,OTHER, 72.67, 165.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12489,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 64.50,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12490,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.68,,OUTPAT REV HCPCS COMBO 1, 48.71,OTHER, 32.68, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12491,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 120.73,,OUTPAT REV HCPCS COMBO 1, 179.95,OTHER, 120.73, 275.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12492,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 76.91,,OUTPAT REV HCPCS COMBO 1, 114.63,OTHER, 76.91, 175.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12493,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 17.56,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12494,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12495,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 17.56,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12496,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 17.56,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12497,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 60.63,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12498,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.53,,OUTPAT REV HCPCS COMBO 1, 67.87,OTHER, 45.53, 103.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12499,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 68.37,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12500,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 68.37,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12501,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 68.37,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12502,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 58.05,,OUTPAT REV HCPCS COMBO 1, 86.52,OTHER, 58.05, 132.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12503,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 120.81,OTHER, 36.98, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12504,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 120.81,OTHER, 36.98, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12505,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 29.76,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12506,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 29.76,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12507,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 29.76,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12508,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 17.75,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12509,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 17.75,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12510,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 17.75,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12511,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 5.59,,OUTPAT REV HCPCS COMBO 1, 7.12,OTHER, 3.24, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12512,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 8.07,OTHER, 3.12, 14.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12513,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 27.22,,OUTPAT REV HCPCS COMBO 1, 33.86,OTHER, 12.40, 62.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12514,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 27.22,,OUTPAT REV HCPCS COMBO 1, 33.86,OTHER, 12.40, 62.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12515,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 64.07,,OUTPAT REV HCPCS COMBO 1, 75.71,OTHER, 12.40, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12516,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 64.07,,OUTPAT REV HCPCS COMBO 1, 75.71,OTHER, 12.40, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12517,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 106.06,,OUTPAT REV HCPCS COMBO 1, 145.60,OTHER, 105.66, 241.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12518,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 106.06,,OUTPAT REV HCPCS COMBO 1, 145.60,OTHER, 105.66, 241.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12519,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 211.56,,OUTPAT REV HCPCS COMBO 1, 262.66,OTHER, 94.12, 482.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12520,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 350.08,,OUTPAT REV HCPCS COMBO 1, 428.98,OTHER, 131.99, 797.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12521,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 87.01,,OUTPAT REV HCPCS COMBO 1, 129.68,OTHER, 87.01, 198.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12522,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 164.26,,OUTPAT REV HCPCS COMBO 1, 244.83,OTHER, 164.26, 374.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12523,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 164.26,,OUTPAT REV HCPCS COMBO 1, 244.83,OTHER, 164.26, 374.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12524,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.44,,OUTPAT REV HCPCS COMBO 1, 53.15,OTHER, 6.50, 103.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12525,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 31.79,,OUTPAT REV HCPCS COMBO 1, 38.90,OTHER, 11.76, 72.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12526,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 117.64,,OUTPAT REV HCPCS COMBO 1, 146.83,OTHER, 55.61, 268.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12527,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 16.23,,OUTPAT REV HCPCS COMBO 1, 20.13,OTHER, 7.13, 37.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12528,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 16.23,,OUTPAT REV HCPCS COMBO 1, 20.13,OTHER, 7.13, 37.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12529,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 23.11,,OUTPAT REV HCPCS COMBO 1, 28.92,OTHER, 11.21, 52.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12530,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 23.11,,OUTPAT REV HCPCS COMBO 1, 28.92,OTHER, 11.21, 52.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12531,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 51.60,,OUTPAT REV HCPCS COMBO 1, 60.58,OTHER, 8.33, 117.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12532,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 51.60,,OUTPAT REV HCPCS COMBO 1, 60.58,OTHER, 8.33, 117.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12533,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 41.87,,OUTPAT REV HCPCS COMBO 1, 50.88,OTHER, 13.98, 95.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12534,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 58.52,,OUTPAT REV HCPCS COMBO 1, 71.06,OTHER, 19.36, 133.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12535,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 92.38,,OUTPAT REV HCPCS COMBO 1, 109.86,OTHER, 20.82, 210.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12536,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.53,,OUTPAT REV HCPCS COMBO 1, 80.16,OTHER, 24.14, 149.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12537,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.53,,OUTPAT REV HCPCS COMBO 1, 80.16,OTHER, 24.14, 149.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12538,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 63.10,OTHER, 20.98, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12539,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 63.10,OTHER, 20.98, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12540,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 42.77,,OUTPAT REV HCPCS COMBO 1, 50.79,OTHER, 9.34, 97.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12541,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 42.77,,OUTPAT REV HCPCS COMBO 1, 50.79,OTHER, 9.34, 97.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12542,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 79.55,,OUTPAT REV HCPCS COMBO 1, 100.38,OTHER, 42.16, 181.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12543,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 97.65,,OUTPAT REV HCPCS COMBO 1, 121.92,OTHER, 46.34, 222.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12544,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 37.84,,OUTPAT REV HCPCS COMBO 1, 50.20,OTHER, 30.37, 86.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12545,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 96.70,,OUTPAT REV HCPCS COMBO 1, 116.31,OTHER, 27.31, 220.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12546,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 40.85,,OUTPAT REV HCPCS COMBO 1, 49.78,OTHER, 14.24, 93.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12547,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 50.98,,OUTPAT REV HCPCS COMBO 1, 63.44,OTHER, 23.30, 116.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12548,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 30.50,,OUTPAT REV HCPCS COMBO 1, 36.36,OTHER, 7.22, 69.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12549,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 30.50,,OUTPAT REV HCPCS COMBO 1, 36.36,OTHER, 7.22, 69.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12550,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 27.61,,OUTPAT REV HCPCS COMBO 1, 33.07,OTHER, 7.22, 62.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12551,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 15.70,,OUTPAT REV HCPCS COMBO 1, 19.33,OTHER, 6.31, 35.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12552,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.02,,OUTPAT REV HCPCS COMBO 1, 33.34,OTHER, 6.38, 63.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12553,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 56.73,OTHER, 22.92, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12554,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 100.38,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12555,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 107.07,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12556,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 100.38,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12557,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 100.80,,OUTPAT REV HCPCS COMBO 1, 123.66,OTHER, 38.58, 229.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12558,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.45,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12559,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.45,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12560,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.45,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12561,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 56.84,,OUTPAT REV HCPCS COMBO 1, 69.24,OTHER, 19.70, 129.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12562,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 42.18,,OUTPAT REV HCPCS COMBO 1, 49.97,OTHER, 8.69, 96.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12563,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 35.26,,OUTPAT REV HCPCS COMBO 1, 44.47,OTHER, 18.58, 80.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12564,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 53.64,,OUTPAT REV HCPCS COMBO 1, 65.14,OTHER, 17.74, 122.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12565,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 71.10,,OUTPAT REV HCPCS COMBO 1, 87.25,OTHER, 27.30, 162.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12566,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 71.10,,OUTPAT REV HCPCS COMBO 1, 87.25,OTHER, 27.30, 162.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12567,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 46.87,,OUTPAT REV HCPCS COMBO 1, 59.01,OTHER, 24.29, 106.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12568,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 104.53,,OUTPAT REV HCPCS COMBO 1, 127.93,OTHER, 36.36, 240.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12569,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 105.53,,OUTPAT REV HCPCS COMBO 1, 127.93,OTHER, 36.36, 240.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12570,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.46,OTHER, 15.47, 105.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12571,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 10.32,,OUTPAT REV HCPCS COMBO 1, 13.69,OTHER, 8.28, 23.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12572,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 61.16,,OUTPAT REV HCPCS COMBO 1, 73.71,OTHER, 17.87, 139.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12573,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 72.21,,OUTPAT REV HCPCS COMBO 1, 87.73,OTHER, 24.06, 164.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12574,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 72.21,,OUTPAT REV HCPCS COMBO 1, 87.73,OTHER, 24.06, 164.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12575,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 53.47,,OUTPAT REV HCPCS COMBO 1, 66.31,OTHER, 23.47, 121.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12576,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 53.47,,OUTPAT REV HCPCS COMBO 1, 66.31,OTHER, 23.47, 121.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12577,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 160.20,,OUTPAT REV HCPCS COMBO 1, 190.19,OTHER, 34.69, 365.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12578,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 181.18,,OUTPAT REV HCPCS COMBO 1, 214.01,OTHER, 34.69, 412.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12579,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 39.85,,OUTPAT REV HCPCS COMBO 1, 47.49,OTHER, 9.37, 90.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12580,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 39.85,,OUTPAT REV HCPCS COMBO 1, 47.49,OTHER, 9.37, 90.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12581,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.68,,OUTPAT REV HCPCS COMBO 1, 41.70,OTHER, 19.28, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12582,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 49.11,,OUTPAT REV HCPCS COMBO 1, 59.73,OTHER, 16.63, 111.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12583,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 26.30,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12584,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 26.30,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12585,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 26.30,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12586,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.88,,OUTPAT REV HCPCS COMBO 1, 39.11,OTHER, 7.46, 74.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12587,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.88,,OUTPAT REV HCPCS COMBO 1, 39.11,OTHER, 7.46, 74.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12588,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 79.45,,OUTPAT REV HCPCS COMBO 1, 93.47,OTHER, 13.62, 181.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12589,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 79.45,,OUTPAT REV HCPCS COMBO 1, 93.47,OTHER, 13.62, 181.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12590,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.12,,OUTPAT REV HCPCS COMBO 1, 45.06,OTHER, 16.97, 82.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12591,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.16,,OUTPAT REV HCPCS COMBO 1, 76.21,OTHER, 9.31, 148.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12592,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 59.05,,OUTPAT REV HCPCS COMBO 1, 72.23,OTHER, 21.72, 134.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12593,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 59.05,,OUTPAT REV HCPCS COMBO 1, 72.23,OTHER, 21.72, 134.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12594,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 60.77,,OUTPAT REV HCPCS COMBO 1, 75.36,OTHER, 26.66, 138.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12595,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 60.77,,OUTPAT REV HCPCS COMBO 1, 75.36,OTHER, 26.66, 138.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12596,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 104.58,,OUTPAT REV HCPCS COMBO 1, 127.42,OTHER, 36.38, 238.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12597,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 104.58,,OUTPAT REV HCPCS COMBO 1, 127.42,OTHER, 36.38, 238.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12598,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 76.99,,OUTPAT REV HCPCS COMBO 1, 93.87,OTHER, 27.06, 175.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12599,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 110.87,,OUTPAT REV HCPCS COMBO 1, 135.49,OTHER, 40.24, 252.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12600,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 110.87,,OUTPAT REV HCPCS COMBO 1, 135.49,OTHER, 40.24, 252.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12601,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 64.07,,OUTPAT REV HCPCS COMBO 1, 83.83,OTHER, 46.51, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12602,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 57.62,,OUTPAT REV HCPCS COMBO 1, 73.72,OTHER, 34.82, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12603,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 58.91,,OUTPAT REV HCPCS COMBO 1, 75.45,OTHER, 35.93, 134.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12604,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 100.08,,OUTPAT REV HCPCS COMBO 1, 121.64,OTHER, 33.53, 228.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12605,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 59.37,,OUTPAT REV HCPCS COMBO 1, 69.17,OTHER, 7.34, 135.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12606,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 104.71,,OUTPAT REV HCPCS COMBO 1, 124.67,OTHER, 24.19, 238.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12607,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 63.21,,OUTPAT REV HCPCS COMBO 1, 76.46,OTHER, 19.63, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12608,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 58.51,,OUTPAT REV HCPCS COMBO 1, 71.48,OTHER, 21.17, 133.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12609,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 182.22,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12610,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 66.65,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12611,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.48,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12612,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.48,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12613,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.48,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12614,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 52.23,,OUTPAT REV HCPCS COMBO 1, 64.96,OTHER, 23.70, 119.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12615,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.38,,OUTPAT REV HCPCS COMBO 1, 34.98,OTHER, 11.54, 64.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12616,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 171.35,,OUTPAT REV HCPCS COMBO 1, 203.52,OTHER, 37.54, 390.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12617,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 49.02,,OUTPAT REV HCPCS COMBO 1, 61.71,OTHER, 25.39, 111.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12618,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 21.39,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12619,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 21.39,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12620,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 21.39,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12621,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 23.75,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12622,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 23.75,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12623,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 23.75,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12624,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 11.27,,OUTPAT REV HCPCS COMBO 1, 14.14,OTHER, 5.66, 25.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12625,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 55.33,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 6.84, 126.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12626,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 55.33,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 6.84, 126.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12627,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 48.07,,OUTPAT REV HCPCS COMBO 1, 57.91,OTHER, 13.97, 109.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12628,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 30.89,,OUTPAT REV HCPCS COMBO 1, 37.55,OTHER, 10.37, 70.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12629,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 77.81,,OUTPAT REV HCPCS COMBO 1, 94.73,OTHER, 26.76, 177.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12630,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 77.81,,OUTPAT REV HCPCS COMBO 1, 94.73,OTHER, 26.76, 177.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12631,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 77.64,,OUTPAT REV HCPCS COMBO 1, 94.52,OTHER, 26.66, 176.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12632,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 77.64,,OUTPAT REV HCPCS COMBO 1, 94.52,OTHER, 26.66, 176.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12633,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 55.24,,OUTPAT REV HCPCS COMBO 1, 67.05,OTHER, 18.12, 125.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12634,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 59.34,,OUTPAT REV HCPCS COMBO 1, 74.92,OTHER, 31.62, 135.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12635,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 39.60,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12636,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 39.60,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12637,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 39.60,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12638,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 82.50,,OUTPAT REV HCPCS COMBO 1, 99.83,OTHER, 25.80, 188.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12639,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 129.43,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12640,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12641,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12642,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12643,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12644,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12645,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 127.54,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12646,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 77.00,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12647,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 118.72,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12648,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 18.49,,OUTPAT REV HCPCS COMBO 1, 25.93,OTHER, 18.49, 42.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12649,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 57.34,,OUTPAT REV HCPCS COMBO 1, 69.04,OTHER, 16.46, 130.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12650,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.69,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12651,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.69,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12652,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.69,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12653,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12654,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12655,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12656,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12657,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 58.18,,OUTPAT REV HCPCS COMBO 1, 70.04,OTHER, 16.66, 132.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12658,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 37.18,,OUTPAT REV HCPCS COMBO 1, 51.00,OTHER, 8.70, 111.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12659,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 48.99,,OUTPAT REV HCPCS COMBO 1, 51.00,OTHER, 8.70, 111.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12660,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 71.38,,OUTPAT REV HCPCS COMBO 1, 85.45,OTHER, 18.42, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12661,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.77,OTHER, 28.37, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12662,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 44.57,,OUTPAT REV HCPCS COMBO 1, 54.77,OTHER, 17.44, 101.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12663,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 44.57,,OUTPAT REV HCPCS COMBO 1, 54.77,OTHER, 17.44, 101.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12664,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 60.48,OTHER, 9.92, 116.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12665,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 60.48,OTHER, 9.92, 116.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12666,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 117.27,,OUTPAT REV HCPCS COMBO 1, 149.05,OTHER, 66.68, 267.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12667,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 27.95,,OUTPAT REV HCPCS COMBO 1, 43.46,OTHER, 27.95, 63.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12668,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 34.70,,OUTPAT REV HCPCS COMBO 1, 43.01,OTHER, 15.12, 79.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12669,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 34.70,,OUTPAT REV HCPCS COMBO 1, 43.01,OTHER, 15.12, 79.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12670,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 33.76,,OUTPAT REV HCPCS COMBO 1, 40.64,OTHER, 9.65, 76.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12671,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 172.39,,OUTPAT REV HCPCS COMBO 1, 204.04,OTHER, 34.72, 392.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12672,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.72,,OUTPAT REV HCPCS COMBO 1, 57.49,OTHER, 23.41, 104.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12673,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 135.39,,OUTPAT REV HCPCS COMBO 1, 159.56,OTHER, 24.40, 308.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12674,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 135.39,,OUTPAT REV HCPCS COMBO 1, 159.56,OTHER, 24.40, 308.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12675,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 71.67,,OUTPAT REV HCPCS COMBO 1, 74.79,OTHER, 18.60, 163.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12676,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 52.25,,OUTPAT REV HCPCS COMBO 1, 74.79,OTHER, 18.60, 163.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12677,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 94.17,,OUTPAT REV HCPCS COMBO 1, 120.40,OTHER, 56.53, 214.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12678,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 94.17,,OUTPAT REV HCPCS COMBO 1, 120.40,OTHER, 56.53, 214.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12679,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 91.30,,OUTPAT REV HCPCS COMBO 1, 110.95,OTHER, 30.54, 208.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12680,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.70,,OUTPAT REV HCPCS COMBO 1, 54.17,OTHER, 9.52, 104.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12681,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 37.08,,OUTPAT REV HCPCS COMBO 1, 44.45,OTHER, 9.82, 84.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12682,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 37.08,,OUTPAT REV HCPCS COMBO 1, 44.45,OTHER, 9.82, 84.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12683,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 71.50,,OUTPAT REV HCPCS COMBO 1, 86.15,OTHER, 20.81, 162.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12684,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 116.98,,OUTPAT REV HCPCS COMBO 1, 147.00,OTHER, 59.45, 266.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12685,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 116.98,,OUTPAT REV HCPCS COMBO 1, 147.00,OTHER, 59.45, 266.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12686,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.68,,OUTPAT REV HCPCS COMBO 1, 43.75,OTHER, 27.89, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12687,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 158.40,,OUTPAT REV HCPCS COMBO 1, 186.61,OTHER, 28.27, 361.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12688,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 45.87,OTHER, 7.46, 92.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12689,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 40.68,,OUTPAT REV HCPCS COMBO 1, 45.87,OTHER, 7.46, 92.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12690,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 29.56,,OUTPAT REV HCPCS COMBO 1, 35.19,OTHER, 6.83, 67.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12691,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 29.56,,OUTPAT REV HCPCS COMBO 1, 35.19,OTHER, 6.83, 67.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12692,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 23.99,,OUTPAT REV HCPCS COMBO 1, 28.87,OTHER, 6.85, 54.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12693,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 13.83,OTHER, 6.82, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12694,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 35.72,,OUTPAT REV HCPCS COMBO 1, 45.56,OTHER, 21.01, 81.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12695,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 75.35,,OUTPAT REV HCPCS COMBO 1, 92.72,OTHER, 30.04, 171.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12696,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 75.35,,OUTPAT REV HCPCS COMBO 1, 92.72,OTHER, 30.04, 171.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12697,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 82.30,,OUTPAT REV HCPCS COMBO 1, 102.79,OTHER, 39.19, 187.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12698,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 79.71,,OUTPAT REV HCPCS COMBO 1, 97.17,OTHER, 27.91, 181.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12699,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 71.08,,OUTPAT REV HCPCS COMBO 1, 90.21,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12700,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 76.69,,OUTPAT REV HCPCS COMBO 1, 90.21,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12701,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 76.69,,OUTPAT REV HCPCS COMBO 1, 93.39,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12702,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 20.61,,OUTPAT REV HCPCS COMBO 1, 24.66,OTHER, 5.28, 46.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12703,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 20.61,,OUTPAT REV HCPCS COMBO 1, 24.66,OTHER, 5.28, 46.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12704,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12705,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12706,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12707,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 35.17,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12708,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 35.17,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12709,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.73,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12710,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 171.18,,OUTPAT REV HCPCS COMBO 1, 144.06,OTHER, 15.47, 390.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12711,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 76.05,,OUTPAT REV HCPCS COMBO 1, 144.06,OTHER, 15.47, 390.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12712,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.58,,OUTPAT REV HCPCS COMBO 1, 141.59,OTHER, 25.68, 394.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12713,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 173.02,,OUTPAT REV HCPCS COMBO 1, 141.59,OTHER, 25.68, 394.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12714,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 112.01,,OUTPAT REV HCPCS COMBO 1, 136.35,OTHER, 38.44, 255.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12715,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 82.46,,OUTPAT REV HCPCS COMBO 1, 103.27,OTHER, 40.46, 187.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12716,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 61.06,,OUTPAT REV HCPCS COMBO 1, 76.88,OTHER, 31.67, 139.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12717,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 151.36,,OUTPAT REV HCPCS COMBO 1, 178.83,OTHER, 29.15, 344.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12718,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 71.31,,OUTPAT REV HCPCS COMBO 1, 88.43,OTHER, 31.30, 162.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12719,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 24.98,,OUTPAT REV HCPCS COMBO 1, 30.02,OTHER, 6.92, 56.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12720,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 24.98,,OUTPAT REV HCPCS COMBO 1, 30.02,OTHER, 6.92, 56.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12721,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 38.86,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12722,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 38.86,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12723,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 7.98,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12724,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 152.72,,OUTPAT REV HCPCS COMBO 1, 180.72,OTHER, 30.61, 348.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12725,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 264.33,,OUTPAT REV HCPCS COMBO 1, 302.95,OTHER, 11.66, 602.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12726,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 64.43,,OUTPAT REV HCPCS COMBO 1, 81.90,OTHER, 36.67, 146.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12727,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12728,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12729,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12730,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12731,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 70.02,,OUTPAT REV HCPCS COMBO 1, 86.80,OTHER, 30.58, 159.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12732,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 70.02,,OUTPAT REV HCPCS COMBO 1, 86.80,OTHER, 30.58, 159.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12733,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 89.69,,OUTPAT REV HCPCS COMBO 1, 107.35,OTHER, 23.12, 204.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12734,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 89.69,,OUTPAT REV HCPCS COMBO 1, 107.35,OTHER, 23.12, 204.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12735,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 44.84,,OUTPAT REV HCPCS COMBO 1, 53.27,OTHER, 9.89, 102.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12736,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 44.84,,OUTPAT REV HCPCS COMBO 1, 53.27,OTHER, 9.89, 102.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12737,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 64.16,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12738,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 64.16,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12739,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 64.16,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12740,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 41.28,,OUTPAT REV HCPCS COMBO 1, 51.95,OTHER, 21.29, 94.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12741,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 59.68,,OUTPAT REV HCPCS COMBO 1, 73.53,OTHER, 24.19, 136.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12742,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 120.40,,OUTPAT REV HCPCS COMBO 1, 154.17,OTHER, 73.24, 274.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12743,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 120.40,,OUTPAT REV HCPCS COMBO 1, 154.17,OTHER, 73.24, 274.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12744,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 39.56,,OUTPAT REV HCPCS COMBO 1, 49.79,OTHER, 20.42, 90.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12745,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.18,,OUTPAT REV HCPCS COMBO 1, 38.32,OTHER, 7.46, 73.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12746,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 30.09,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, 7.63, 68.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12747,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 47.67,,OUTPAT REV HCPCS COMBO 1, 58.51,OTHER, 18.37, 108.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12748,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.73,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 8.27, 74.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12749,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.64,,OUTPAT REV HCPCS COMBO 1, 79.41,OTHER, 20.42, 149.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12750,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.64,,OUTPAT REV HCPCS COMBO 1, 79.41,OTHER, 20.42, 149.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12751,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 64.36,,OUTPAT REV HCPCS COMBO 1, 78.90,OTHER, 24.40, 146.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12752,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 64.36,,OUTPAT REV HCPCS COMBO 1, 78.90,OTHER, 24.40, 146.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12753,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 106.98,,OUTPAT REV HCPCS COMBO 1, 126.89,OTHER, 22.69, 243.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12754,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 69.32,,OUTPAT REV HCPCS COMBO 1, 82.99,OTHER, 17.95, 157.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12755,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 69.32,,OUTPAT REV HCPCS COMBO 1, 82.99,OTHER, 17.95, 157.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12756,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 33.26,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12757,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 33.26,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12758,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 33.26,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12759,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 18.22,,OUTPAT REV HCPCS COMBO 1, 22.60,OTHER, 8.00, 41.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12760,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 18.22,,OUTPAT REV HCPCS COMBO 1, 22.60,OTHER, 8.00, 41.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12761,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 26.70,,OUTPAT REV HCPCS COMBO 1, 31.87,OTHER, 6.50, 60.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12762,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.90,,OUTPAT REV HCPCS COMBO 1, 39.10,OTHER, 7.32, 74.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12763,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 63.71,,OUTPAT REV HCPCS COMBO 1, 76.33,OTHER, 16.72, 145.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12764,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 87.18,,OUTPAT REV HCPCS COMBO 1, 103.71,OTHER, 19.75, 198.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12765,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12766,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12767,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12768,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 69.10,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 29.96, 157.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12769,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 80.90,,OUTPAT REV HCPCS COMBO 1, 97.04,OTHER, 21.67, 184.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12770,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.30,,OUTPAT REV HCPCS COMBO 1, 42.88,OTHER, 6.94, 82.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12771,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 37.42,,OUTPAT REV HCPCS COMBO 1, 43.80,OTHER, 5.47, 85.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12772,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 15.00,,OUTPAT REV HCPCS COMBO 1, 17.85,OTHER, 3.41, 34.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12773,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 15.00,,OUTPAT REV HCPCS COMBO 1, 17.85,OTHER, 3.41, 34.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12774,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 18.18,,OUTPAT REV HCPCS COMBO 1, 21.46,OTHER, 3.41, 41.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12775,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 18.18,,OUTPAT REV HCPCS COMBO 1, 21.46,OTHER, 3.41, 41.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12776,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 22.31,OTHER, .01, 84.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12777,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.94,,OUTPAT REV HCPCS COMBO 1, 22.31,OTHER, .01, 84.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12778,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 37.42,,OUTPAT REV HCPCS COMBO 1, 44.71,OTHER, 9.31, 85.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12779,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 31.95,,OUTPAT REV HCPCS COMBO 1, 37.65,OTHER, 5.75, 72.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12780,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 31.95,,OUTPAT REV HCPCS COMBO 1, 37.65,OTHER, 5.75, 72.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12781,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 16.77,,OUTPAT REV HCPCS COMBO 1, 19.92,OTHER, 3.66, 38.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12782,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 27.38,,OUTPAT REV HCPCS COMBO 1, 32.63,OTHER, 6.46, 62.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12783,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 79.81,,OUTPAT REV HCPCS COMBO 1, 96.77,OTHER, 25.78, 181.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12784,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 106.94,,OUTPAT REV HCPCS COMBO 1, 129.31,OTHER, 33.04, 243.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12785,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 111.37,,OUTPAT REV HCPCS COMBO 1, 130.54,OTHER, 17.06, 253.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12786,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 82.42,,OUTPAT REV HCPCS COMBO 1, 98.34,OTHER, 19.93, 187.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12787,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 73.75,,OUTPAT REV HCPCS COMBO 1, 89.00,OTHER, 22.06, 168.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12788,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 83.42,,OUTPAT REV HCPCS COMBO 1, 98.22,OTHER, 14.66, 190.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12789,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.18,,OUTPAT REV HCPCS COMBO 1, 54.63,OTHER, 13.99, 102.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12790,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 56.33,,OUTPAT REV HCPCS COMBO 1, 70.40,OTHER, 27.00, 128.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12791,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 25.05,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12792,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 24.89,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12793,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 25.05,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12794,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12795,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12796,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12797,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12798,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 35.35,,OUTPAT REV HCPCS COMBO 1, 41.60,OTHER, 6.14, 80.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12799,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 22.36,,OUTPAT REV HCPCS COMBO 1, 26.32,OTHER, 3.89, 50.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12800,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 30.35,,OUTPAT REV HCPCS COMBO 1, 36.35,OTHER, 7.93, 69.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12801,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 73.10,,OUTPAT REV HCPCS COMBO 1, 61.85,OTHER, 8.65, 166.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12802,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.20,,OUTPAT REV HCPCS COMBO 1, 61.85,OTHER, 8.65, 166.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12803,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.15,,OUTPAT REV HCPCS COMBO 1, 76.67,OTHER, 11.26, 148.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12804,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 510.99,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12805,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 138.89,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12806,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12807,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12808,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12809,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12810,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12811,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12812,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12813,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12814,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12815,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12816,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12817,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12818,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12819,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12820,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12821,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12822,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12823,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12824,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12825,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12826,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12827,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12828,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12829,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12830,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12831,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12832,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12833,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12834,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12835,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12836,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12837,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12838,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12839,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12840,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12841,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12842,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 26.51,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12843,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12844,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12845,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12846,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12847,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 13.80,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12848,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12849,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12850,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12851,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12852,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12853,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12854,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12855,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12856,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12857,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12858,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12859,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12860,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12861,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12862,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12863,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12864,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12865,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12866,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 161.14,,OUTPAT REV HCPCS COMBO 1, 189.29,OTHER, 26.45, 367.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12867,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 98.39,,OUTPAT REV HCPCS COMBO 1, 115.17,OTHER, 14.46, 224.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12868,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 57.32,,OUTPAT REV HCPCS COMBO 1, 91.70,OTHER, 17.41, 220.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12869,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 96.87,,OUTPAT REV HCPCS COMBO 1, 91.70,OTHER, 17.41, 220.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12870,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 39.70,,OUTPAT REV HCPCS COMBO 1, 48.91,OTHER, 16.07, 90.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12871,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 37.63,,OUTPAT REV HCPCS COMBO 1, 45.23,OTHER, 10.51, 85.75,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12872,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 13.48,,OUTPAT REV HCPCS COMBO 1, 17.08,OTHER, 7.46, 30.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12873,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 13.48,,OUTPAT REV HCPCS COMBO 1, 17.08,OTHER, 7.46, 30.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12874,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 48.27,,OUTPAT REV HCPCS COMBO 1, 59.25,OTHER, 18.65, 110.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12875,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 75.07,,OUTPAT REV HCPCS COMBO 1, 93.98,OTHER, 36.65, 171.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12876,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 113.28,,OUTPAT REV HCPCS COMBO 1, 137.37,OTHER, 36.65, 258.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12877,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 64.24,,OUTPAT REV HCPCS COMBO 1, 78.46,OTHER, 23.14, 146.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12878,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 56.01,,OUTPAT REV HCPCS COMBO 1, 67.64,OTHER, 17.28, 127.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12879,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 55.87,,OUTPAT REV HCPCS COMBO 1, 67.64,OTHER, 17.28, 127.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12880,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 62.28,,OUTPAT REV HCPCS COMBO 1, 77.69,OTHER, 29.26, 141.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12881,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 51.73,,OUTPAT REV HCPCS COMBO 1, 63.19,OTHER, 18.65, 117.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12882,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 51.66,,OUTPAT REV HCPCS COMBO 1, 65.88,OTHER, 19.79, 127.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12883,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 56.08,,OUTPAT REV HCPCS COMBO 1, 65.88,OTHER, 19.79, 127.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12884,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12885,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12886,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12887,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12888,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 60.90,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12889,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12890,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 51.97,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12891,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 48.44,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12892,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 68.37,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12893,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 104.56,,OUTPAT REV HCPCS COMBO 1, 120.82,OTHER, 17.35, 238.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12894,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 100.94,,OUTPAT REV HCPCS COMBO 1, 120.82,OTHER, 17.35, 238.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12895,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 15.65,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12896,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 64.09,,OUTPAT REV HCPCS COMBO 1, 80.94,OTHER, 29.96, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12897,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.89,,OUTPAT REV HCPCS COMBO 1, 80.94,OTHER, 29.96, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12898,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 68.68,,OUTPAT REV HCPCS COMBO 1, 85.12,OTHER, 29.96, 156.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12899,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 84.81,,OUTPAT REV HCPCS COMBO 1, 103.45,OTHER, 29.96, 193.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12900,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 58.18,,OUTPAT REV HCPCS COMBO 1, 125.05,OTHER, 24.97, 345.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12901,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 151.58,,OUTPAT REV HCPCS COMBO 1, 125.05,OTHER, 24.97, 345.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12902,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 42.94,,OUTPAT REV HCPCS COMBO 1, 50.54,OTHER, 7.46, 97.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12903,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 71.51,,OUTPAT REV HCPCS COMBO 1, 88.87,OTHER, 32.17, 162.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12904,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 52.03,,OUTPAT REV HCPCS COMBO 1, 66.43,OTHER, 30.83, 118.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12905,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 46.01,,OUTPAT REV HCPCS COMBO 1, 57.43,OTHER, 21.72, 104.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12906,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 226.29,,OUTPAT REV HCPCS COMBO 1, 265.06,OTHER, 33.95, 515.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12907,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 63.21,,OUTPAT REV HCPCS COMBO 1, 80.97,OTHER, 38.57, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12908,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 63.21,,OUTPAT REV HCPCS COMBO 1, 80.97,OTHER, 38.57, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12909,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 87.08,,OUTPAT REV HCPCS COMBO 1, 111.82,OTHER, 54.34, 198.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12910,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 141.00,,OUTPAT REV HCPCS COMBO 1, 176.22,OTHER, 67.64, 321.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12911,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 69.45,,OUTPAT REV HCPCS COMBO 1, 88.05,OTHER, 38.57, 158.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12912,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 69.45,,OUTPAT REV HCPCS COMBO 1, 88.05,OTHER, 38.57, 158.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12913,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 57.62,,OUTPAT REV HCPCS COMBO 1, 68.73,OTHER, 13.84, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12914,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 70.14,,OUTPAT REV HCPCS COMBO 1, 96.09,OTHER, 20.95, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12915,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 90.30,,OUTPAT REV HCPCS COMBO 1, 96.09,OTHER, 20.95, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12916,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 57.62,,OUTPAT REV HCPCS COMBO 1, 70.10,OTHER, 19.60, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12917,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 39.55,,OUTPAT REV HCPCS COMBO 1, 46.86,OTHER, 8.16, 90.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12918,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 39.55,,OUTPAT REV HCPCS COMBO 1, 46.86,OTHER, 8.16, 90.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12919,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 150.07,,OUTPAT REV HCPCS COMBO 1, 191.67,OTHER, 89.24, 342.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12920,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 8.04,,OUTPAT REV HCPCS COMBO 1, 12.31,OTHER, 8.04, 18.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12921,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 15.01,,OUTPAT REV HCPCS COMBO 1, 18.56,OTHER, 6.34, 34.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12922,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 27.34,,OUTPAT REV HCPCS COMBO 1, 36.21,OTHER, 21.67, 62.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12923,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.58,,OUTPAT REV HCPCS COMBO 1, 55.25,OTHER, 14.66, 103.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12924,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 31.44,,OUTPAT REV HCPCS COMBO 1, 40.13,OTHER, 18.58, 71.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12925,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 66.54,OTHER, 19.00, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12926,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 72.68,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12927,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 72.68,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12928,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 72.68,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12929,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 19.93,,OUTPAT REV HCPCS COMBO 1, 26.75,OTHER, 17.29, 45.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12930,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 41.68,,OUTPAT REV HCPCS COMBO 1, 91.08,OTHER, 16.51, 254.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12931,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 111.80,,OUTPAT REV HCPCS COMBO 1, 91.08,OTHER, 16.51, 254.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12932,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 40.42,,OUTPAT REV HCPCS COMBO 1, 50.83,OTHER, 20.72, 92.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12933,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 46.87,,OUTPAT REV HCPCS COMBO 1, 59.00,OTHER, 24.26, 106.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12934,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 52.14,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 22.02, 118.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12935,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 46.92,,OUTPAT REV HCPCS COMBO 1, 59.50,OTHER, 26.12, 106.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12936,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 46.92,,OUTPAT REV HCPCS COMBO 1, 59.50,OTHER, 26.12, 106.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12937,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 78.68,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12938,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 47.36,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12939,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 47.36,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12940,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 52.89,,OUTPAT REV HCPCS COMBO 1, 66.70,OTHER, 27.86, 120.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12941,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 52.89,,OUTPAT REV HCPCS COMBO 1, 66.70,OTHER, 27.86, 120.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12942,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 33.97,,OUTPAT REV HCPCS COMBO 1, 43.51,OTHER, 20.72, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12943,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 38.00,,OUTPAT REV HCPCS COMBO 1, 47.68,OTHER, 19.00, 86.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12944,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.58,,OUTPAT REV HCPCS COMBO 1, 58.39,OTHER, 27.86, 103.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12945,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 64.05,,OUTPAT REV HCPCS COMBO 1, 77.47,OTHER, 19.86, 145.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12946,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 50.90,,OUTPAT REV HCPCS COMBO 1, 62.50,OTHER, 19.74, 116.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12947,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 37.53,,OUTPAT REV HCPCS COMBO 1, 46.75,OTHER, 17.35, 85.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12948,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.68,,OUTPAT REV HCPCS COMBO 1, 41.14,OTHER, 16.94, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12949,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 55.83,,OUTPAT REV HCPCS COMBO 1, 67.08,OTHER, 15.47, 127.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12950,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 40.75,,OUTPAT REV HCPCS COMBO 1, 50.52,OTHER, 17.84, 92.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12951,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 21.41,,OUTPAT REV HCPCS COMBO 1, 28.18,OTHER, 16.21, 48.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12952,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 42.33,,OUTPAT REV HCPCS COMBO 1, 52.54,OTHER, 18.79, 96.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12953,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 42.33,,OUTPAT REV HCPCS COMBO 1, 52.54,OTHER, 18.79, 96.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12954,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 41.16,OTHER, 19.07, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12955,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.26,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12956,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.26,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12957,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.26,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12958,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 37.52,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12959,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 38.81,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12960,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 38.81,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12961,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 39.49,,OUTPAT REV HCPCS COMBO 1, 49.38,OTHER, 19.07, 89.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12962,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 66.65,,OUTPAT REV HCPCS COMBO 1, 80.11,OTHER, 18.55, 151.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12963,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 66.65,,OUTPAT REV HCPCS COMBO 1, 80.11,OTHER, 18.55, 151.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12964,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 314.67,,OUTPAT REV HCPCS COMBO 1, 361.76,OTHER, 18.55, 717.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12965,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 138.03,,OUTPAT REV HCPCS COMBO 1, 161.64,OTHER, 20.54, 314.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12966,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 120.30,,OUTPAT REV HCPCS COMBO 1, 158.63,OTHER, 92.44, 274.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12967,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 120.30,,OUTPAT REV HCPCS COMBO 1, 158.63,OTHER, 92.44, 274.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12968,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.75,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12969,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.75,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12970,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.75,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12971,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 102.77,,OUTPAT REV HCPCS COMBO 1, 152.44,OTHER, 102.77, 234.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12972,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12973,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12974,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12975,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12976,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12977,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12978,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12979,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12980,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 127.76,,OUTPAT REV HCPCS COMBO 1, 146.86,OTHER, 7.46, 291.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12981,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 47.30,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12982,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 47.30,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12983,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 47.30,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12984,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 39.16,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12985,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 37.22,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12986,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 39.16,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12987,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12988,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12989,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 168.35,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12990,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 59.99,,OUTPAT REV HCPCS COMBO 1, 70.78,OTHER, 11.16, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12991,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 59.99,,OUTPAT REV HCPCS COMBO 1, 70.78,OTHER, 11.16, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12992,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12993,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12994,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12995,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12996,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12997,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12998,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 59.99,,OUTPAT REV HCPCS COMBO 1, 76.50,OTHER, 35.20, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 12999,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 112.23,,OUTPAT REV HCPCS COMBO 1, 149.18,OTHER, 91.25, 255.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13000,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 68.57,,OUTPAT REV HCPCS COMBO 1, 81.41,OTHER, 14.86, 156.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13001,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 68.57,,OUTPAT REV HCPCS COMBO 1, 81.41,OTHER, 14.86, 156.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13002,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 24.24,,OUTPAT REV HCPCS COMBO 1, 30.76,OTHER, 13.60, 55.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13003,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 61.36,,OUTPAT REV HCPCS COMBO 1, 72.64,OTHER, 12.41, 139.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13004,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 61.36,,OUTPAT REV HCPCS COMBO 1, 72.64,OTHER, 12.41, 139.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13005,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 66.06,,OUTPAT REV HCPCS COMBO 1, 78.26,OTHER, 13.63, 150.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13006,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 66.06,,OUTPAT REV HCPCS COMBO 1, 78.26,OTHER, 13.63, 150.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13007,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 67.12,,OUTPAT REV HCPCS COMBO 1, 78.99,OTHER, 11.64, 152.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13008,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 38.75,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13009,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 38.75,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13010,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 38.75,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13011,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 34.07,,OUTPAT REV HCPCS COMBO 1, 40.96,OTHER, 9.55, 77.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13012,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.91,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13013,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.91,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13014,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.91,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13015,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 70.00,,OUTPAT REV HCPCS COMBO 1, 82.26,OTHER, 11.65, 159.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13016,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 70.00,,OUTPAT REV HCPCS COMBO 1, 82.26,OTHER, 11.65, 159.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13017,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 63.28,,OUTPAT REV HCPCS COMBO 1, 74.74,OTHER, 12.11, 144.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13018,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 76.88,,OUTPAT REV HCPCS COMBO 1, 91.00,OTHER, 15.55, 175.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13019,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 57.47,,OUTPAT REV HCPCS COMBO 1, 68.31,OTHER, 12.82, 130.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13020,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 14.19,,OUTPAT REV HCPCS COMBO 1, 17.74,OTHER, 6.84, 32.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13021,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 17.99,,OUTPAT REV HCPCS COMBO 1, 22.99,OTHER, 10.78, 40.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13022,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 24.94,,OUTPAT REV HCPCS COMBO 1, 29.95,OTHER, 6.84, 56.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13023,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 34.74,,OUTPAT REV HCPCS COMBO 1, 42.41,OTHER, 12.46, 79.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13024,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 24.33,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13025,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 22.66,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13026,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 22.66,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13027,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 22.74,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13028,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 22.74,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13029,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 31.96,,OUTPAT REV HCPCS COMBO 1, 38.14,OTHER, 7.76, 72.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13030,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 31.96,,OUTPAT REV HCPCS COMBO 1, 38.14,OTHER, 7.76, 72.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13031,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 23.16,,OUTPAT REV HCPCS COMBO 1, 28.29,OTHER, 8.38, 52.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13032,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.72,OTHER, 28.16, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13033,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 260.02,,OUTPAT REV HCPCS COMBO 1, 299.39,OTHER, 17.26, 592.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13034,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.69,,OUTPAT REV HCPCS COMBO 1, 40.67,OTHER, 14.88, 74.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13035,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 34.45,,OUTPAT REV HCPCS COMBO 1, 43.08,OTHER, 16.61, 78.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13036,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 102.77,,OUTPAT REV HCPCS COMBO 1, 121.25,OTHER, 19.08, 234.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13037,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.89,OTHER, 28.87, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13038,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13039,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13040,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13041,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13042,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13043,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 162.17,,OUTPAT REV HCPCS COMBO 1, 198.86,OTHER, 61.69, 369.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13044,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 162.17,,OUTPAT REV HCPCS COMBO 1, 198.86,OTHER, 61.69, 369.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13045,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 67.57,,OUTPAT REV HCPCS COMBO 1, 100.71,OTHER, 67.57, 153.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13046,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 182.09,,OUTPAT REV HCPCS COMBO 1, 221.47,OTHER, 61.69, 415.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13047,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 56.71,,OUTPAT REV HCPCS COMBO 1, 76.43,OTHER, 50.53, 129.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13048,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 207.69,,OUTPAT REV HCPCS COMBO 1, 265.03,OTHER, 122.54, 473.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13049,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13050,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 64.50,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13051,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 64.50,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13052,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 266.63,,OUTPAT REV HCPCS COMBO 1, 445.68,OTHER, 266.63, 607.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13053,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13054,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13055,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13056,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 160.23,,OUTPAT REV HCPCS COMBO 1, 193.99,OTHER, 50.53, 365.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13057,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 160.23,,OUTPAT REV HCPCS COMBO 1, 193.99,OTHER, 50.53, 365.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13058,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13059,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 142.33,,OUTPAT REV HCPCS COMBO 1, 173.66,OTHER, 50.53, 324.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13060,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.89,OTHER, 28.87, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13061,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 75.34,,OUTPAT REV HCPCS COMBO 1, 204.22,OTHER, 50.53, 599.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13062,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 263.13,,OUTPAT REV HCPCS COMBO 1, 204.22,OTHER, 50.53, 599.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13063,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 116.09,,OUTPAT REV HCPCS COMBO 1, 146.52,OTHER, 61.69, 264.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13064,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 116.09,,OUTPAT REV HCPCS COMBO 1, 146.52,OTHER, 61.69, 264.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13065,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 62.25,OTHER, 23.83, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13066,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 62.25,OTHER, 23.83, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13067,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 33.97,,OUTPAT REV HCPCS COMBO 1, 43.07,OTHER, 18.86, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13068,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 33.97,,OUTPAT REV HCPCS COMBO 1, 43.07,OTHER, 18.86, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13069,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 33.97,,OUTPAT REV HCPCS COMBO 1, 44.25,OTHER, 23.81, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13070,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 17.88,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13071,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 83.33,,OUTPAT REV HCPCS COMBO 1, 100.14,OTHER, 23.14, 189.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13072,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 627.37,,OUTPAT REV HCPCS COMBO 1, 800.72,OTHER, 370.73, 1429.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13073,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 627.37,,OUTPAT REV HCPCS COMBO 1, 800.72,OTHER, 370.73, 1429.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13074,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 59.91,OTHER, 38.32, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13075,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 59.91,OTHER, 38.32, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13076,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 238.65,,OUTPAT REV HCPCS COMBO 1, 294.34,OTHER, 97.97, 543.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13077,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13078,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13079,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 13.33,,OUTPAT REV HCPCS COMBO 1, 16.75,OTHER, 6.79, 30.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13080,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 13.33,,OUTPAT REV HCPCS COMBO 1, 16.75,OTHER, 6.79, 30.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13081,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 48.34,,OUTPAT REV HCPCS COMBO 1, 56.81,OTHER, 8.06, 110.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13082,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.99,,OUTPAT REV HCPCS COMBO 1, 39.98,OTHER, 10.56, 75.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13083,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 33.11,,OUTPAT REV HCPCS COMBO 1, 41.73,OTHER, 17.35, 75.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13084,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2550.94,,OUTPAT REV HCPCS COMBO 1, 3802.17,OTHER, 2550.94, 5813.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13085,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 48.44,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13086,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 48.44,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13087,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 12.69,,OUTPAT REV HCPCS COMBO 1, 23.30,OTHER, 12.69, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13088,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 25.59,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13089,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 12.79,,OUTPAT REV HCPCS COMBO 1, 23.42,OTHER, 12.79, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13090,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 55.47,,OUTPAT REV HCPCS COMBO 1, 82.68,OTHER, 55.47, 126.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13091,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13092,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.79,,OUTPAT REV HCPCS COMBO 1, 149.84,OTHER, 65.79, 315.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13093,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.79,,OUTPAT REV HCPCS COMBO 1, 149.84,OTHER, 65.79, 315.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13094,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 59.75,,OUTPAT REV HCPCS COMBO 1, 89.06,OTHER, 59.75, 136.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13095,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 21.50,,OUTPAT REV HCPCS COMBO 1, 41.40,OTHER, 21.50, 71.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13096,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 21.50,,OUTPAT REV HCPCS COMBO 1, 41.40,OTHER, 21.50, 71.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13097,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 255.16,,OUTPAT REV HCPCS COMBO 1, 356.50,OTHER, 255.16, 581.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13098,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 533.11,,OUTPAT REV HCPCS COMBO 1, 687.64,OTHER, 345.38, 1214.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13099,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 135.24,,OUTPAT REV HCPCS COMBO 1, 201.57,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13100,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13101,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13102,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.55,,OUTPAT REV HCPCS COMBO 1, 60.00,OTHER, 36.55, 83.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13103,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 22.12,,OUTPAT REV HCPCS COMBO 1, 36.74,OTHER, 22.12, 50.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13104,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 22.12,,OUTPAT REV HCPCS COMBO 1, 36.74,OTHER, 22.12, 50.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13105,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13106,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13107,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13108,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13109,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13110,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13111,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13112,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 34.29,,OUTPAT REV HCPCS COMBO 1, 51.11,OTHER, 34.29, 78.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13113,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 58.79,,OUTPAT REV HCPCS COMBO 1, 87.62,OTHER, 58.79, 133.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13114,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 58.79,,OUTPAT REV HCPCS COMBO 1, 87.62,OTHER, 58.79, 133.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13115,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13116,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 67.85,,OUTPAT REV HCPCS COMBO 1, 111.30,OTHER, 67.85, 154.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13117,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 67.85,,OUTPAT REV HCPCS COMBO 1, 111.30,OTHER, 67.85, 154.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13118,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13119,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13120,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 73.49,,OUTPAT REV HCPCS COMBO 1, 104.75,OTHER, 73.49, 167.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13121,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 73.49,,OUTPAT REV HCPCS COMBO 1, 104.75,OTHER, 73.49, 167.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13122,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 4.30,,OUTPAT REV HCPCS COMBO 1, 12.78,OTHER, 4.30, 33.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13123,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 14.22,,OUTPAT REV HCPCS COMBO 1, 17.36,OTHER, 5.09, 32.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13124,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 130.68,,OUTPAT REV HCPCS COMBO 1, 184.48,OTHER, 130.68, 297.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13125,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 146.42,,OUTPAT REV HCPCS COMBO 1, 202.35,OTHER, 146.42, 333.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13126,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 63.61,,OUTPAT REV HCPCS COMBO 1, 99.37,OTHER, 63.61, 144.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13127,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.39,,OUTPAT REV HCPCS COMBO 1, 88.44,OTHER, 59.56, 149.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13128,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 84.22,,OUTPAT REV HCPCS COMBO 1, 131.72,OTHER, 84.22, 191.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13129,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 82.81,,OUTPAT REV HCPCS COMBO 1, 117.05,OTHER, 82.81, 188.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13130,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 126.51,,OUTPAT REV HCPCS COMBO 1, 179.75,OTHER, 126.51, 288.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13131,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 109.46,,OUTPAT REV HCPCS COMBO 1, 158.52,OTHER, 109.46, 249.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13132,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 132.20,,OUTPAT REV HCPCS COMBO 1, 186.21,OTHER, 132.20, 301.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13133,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 63.26,,OUTPAT REV HCPCS COMBO 1, 83.96,OTHER, 50.93, 144.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13134,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 102.00,,OUTPAT REV HCPCS COMBO 1, 167.44,OTHER, 102.00, 232.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13135,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 106.26,,OUTPAT REV HCPCS COMBO 1, 172.28,OTHER, 106.26, 242.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13136,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 25.59,,OUTPAT REV HCPCS COMBO 1, 49.86,OTHER, 25.59, 87.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13137,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 106.61,,OUTPAT REV HCPCS COMBO 1, 141.43,OTHER, 85.51, 242.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13138,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.42,,OUTPAT REV HCPCS COMBO 1, 69.71,OTHER, 45.42, 103.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13139,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 120.47,,OUTPAT REV HCPCS COMBO 1, 177.65,OTHER, 120.47, 274.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13140,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 130.87,,OUTPAT REV HCPCS COMBO 1, 189.46,OTHER, 130.87, 298.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13141,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 210.54,,OUTPAT REV HCPCS COMBO 1, 279.93,OTHER, 171.54, 479.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13142,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 197.39,,OUTPAT REV HCPCS COMBO 1, 265.00,OTHER, 171.54, 449.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13143,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 108.18,,OUTPAT REV HCPCS COMBO 1, 149.90,OTHER, 108.18, 246.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13144,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 137.41,,OUTPAT REV HCPCS COMBO 1, 167.02,OTHER, 46.09, 313.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13145,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 57.35,,OUTPAT REV HCPCS COMBO 1, 76.10,OTHER, 46.09, 130.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13146,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 120.09,,OUTPAT REV HCPCS COMBO 1, 147.35,OTHER, 46.09, 273.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13147,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 174.02,,OUTPAT REV HCPCS COMBO 1, 227.22,OTHER, 124.32, 396.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13148,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 234.14,,OUTPAT REV HCPCS COMBO 1, 295.49,OTHER, 124.32, 533.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13149,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 74.67,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 74.67, 170.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13150,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 110.85,,OUTPAT REV HCPCS COMBO 1, 155.48,OTHER, 110.85, 252.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13151,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 17.18,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13152,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 17.18,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13153,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 17.18,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13154,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 8.41,,OUTPAT REV HCPCS COMBO 1, 36.72,OTHER, 8.41, 114.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13155,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 158.39,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 114.13, 360.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13156,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 158.39,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 114.13, 360.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13157,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 391.14,,OUTPAT REV HCPCS COMBO 1, 526.62,OTHER, 346.21, 891.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13158,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13159,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13160,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 132.44,,OUTPAT REV HCPCS COMBO 1, 162.12,OTHER, 49.24, 301.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13161,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 106.64,,OUTPAT REV HCPCS COMBO 1, 140.39,OTHER, 80.99, 243.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13162,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 106.64,,OUTPAT REV HCPCS COMBO 1, 140.39,OTHER, 80.99, 243.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13163,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 136.31,,OUTPAT REV HCPCS COMBO 1, 166.97,OTHER, 51.13, 310.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13164,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 37.67,,OUTPAT REV HCPCS COMBO 1, 54.96,OTHER, 37.67, 85.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13165,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.39,,OUTPAT REV HCPCS COMBO 1, 86.43,OTHER, 51.13, 149.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13166,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 699.47,,OUTPAT REV HCPCS COMBO 1, 950.56,OTHER, 656.16, 1594.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13167,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13168,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 399.90,,OUTPAT REV HCPCS COMBO 1, 545.72,OTHER, 384.68, 911.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13169,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 399.90,,OUTPAT REV HCPCS COMBO 1, 545.72,OTHER, 384.68, 911.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13170,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13171,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13172,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 473.98,,OUTPAT REV HCPCS COMBO 1, 591.97,OTHER, 225.62, 1080.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13173,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13174,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 200.25,,OUTPAT REV HCPCS COMBO 1, 250.40,OTHER, 96.59, 456.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13175,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 200.25,,OUTPAT REV HCPCS COMBO 1, 250.40,OTHER, 96.59, 456.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13176,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13177,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 449.04,,OUTPAT REV HCPCS COMBO 1, 563.65,OTHER, 225.62, 1023.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13178,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13179,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 70.09,,OUTPAT REV HCPCS COMBO 1, 113.30,OTHER, 70.09, 159.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13180,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 70.09,,OUTPAT REV HCPCS COMBO 1, 113.30,OTHER, 70.09, 159.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13181,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13182,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13183,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 215.00,,OUTPAT REV HCPCS COMBO 1, 297.88,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13184,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13185,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 201.13,,OUTPAT REV HCPCS COMBO 1, 262.11,OTHER, 141.55, 458.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13186,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 201.13,,OUTPAT REV HCPCS COMBO 1, 262.11,OTHER, 141.55, 458.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13187,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13188,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13189,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 545.87,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13190,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 545.87,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13191,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 383.08,OTHER, 225.62, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13192,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 545.87,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13193,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13194,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13195,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13196,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13197,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13198,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13199,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13200,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13201,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13202,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13203,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13204,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13205,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 529.82,,OUTPAT REV HCPCS COMBO 1, 655.39,OTHER, 225.62, 1207.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13206,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13207,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1114.13,,OUTPAT REV HCPCS COMBO 1, 1042.14,OTHER, 284.89, 2539.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13208,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 601.78,,OUTPAT REV HCPCS COMBO 1, 1042.14,OTHER, 284.89, 2539.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13209,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 187.48,,OUTPAT REV HCPCS COMBO 1, 184.77,OTHER, 39.56, 427.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13210,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 39.56,,OUTPAT REV HCPCS COMBO 1, 184.77,OTHER, 39.56, 427.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13211,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 452.95,,OUTPAT REV HCPCS COMBO 1, 547.41,OTHER, 138.71, 1032.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13212,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 154.36,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13213,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 154.36,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13214,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 125.79,,OUTPAT REV HCPCS COMBO 1, 199.86,OTHER, 125.79, 286.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13215,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 125.79,,OUTPAT REV HCPCS COMBO 1, 199.86,OTHER, 125.79, 286.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13216,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 263.32,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13217,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 345.29,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13218,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 379.26,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13219,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 263.32,,OUTPAT REV HCPCS COMBO 1, 332.46,OTHER, 140.42, 600.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13220,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 160.29,,OUTPAT REV HCPCS COMBO 1, 239.03,OTHER, 160.29, 365.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13221,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 160.29,,OUTPAT REV HCPCS COMBO 1, 239.03,OTHER, 160.29, 365.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13222,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 174.98,OTHER, 103.88, 239.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13223,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 136.10,OTHER, 76.16, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13224,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 74.39,,OUTPAT REV HCPCS COMBO 1, 140.33,OTHER, 74.39, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13225,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 182.75,,OUTPAT REV HCPCS COMBO 1, 228.33,OTHER, 87.35, 416.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13226,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 22.94,,OUTPAT REV HCPCS COMBO 1, 34.19,OTHER, 22.94, 52.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13227,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13228,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 140.89,,OUTPAT REV HCPCS COMBO 1, 182.46,OTHER, 94.34, 321.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13229,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 140.89,,OUTPAT REV HCPCS COMBO 1, 182.46,OTHER, 94.34, 321.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13230,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 61.67,,OUTPAT REV HCPCS COMBO 1, 125.89,OTHER, 61.67, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13231,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 61.67,,OUTPAT REV HCPCS COMBO 1, 125.89,OTHER, 61.67, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13232,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 316.56,,OUTPAT REV HCPCS COMBO 1, 415.63,OTHER, 235.80, 721.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13233,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1397.50,,OUTPAT REV HCPCS COMBO 1, 1853.96,OTHER, 1121.15, 3185.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13234,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1397.50,,OUTPAT REV HCPCS COMBO 1, 1853.96,OTHER, 1121.15, 3185.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13235,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1677.00,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13236,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1677.00,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13237,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1677.00,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13238,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 116.62,,OUTPAT REV HCPCS COMBO 1, 152.82,OTHER, 85.61, 265.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13239,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 127.40,,OUTPAT REV HCPCS COMBO 1, 165.98,OTHER, 89.47, 290.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13240,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 206.52,,OUTPAT REV HCPCS COMBO 1, 260.74,OTHER, 110.12, 470.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13241,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 206.52,,OUTPAT REV HCPCS COMBO 1, 260.74,OTHER, 110.12, 470.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13242,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 77.49,,OUTPAT REV HCPCS COMBO 1, 96.89,OTHER, 37.34, 176.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13243,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 77.49,,OUTPAT REV HCPCS COMBO 1, 96.89,OTHER, 37.34, 176.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13244,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 245.81,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13245,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 245.81,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13246,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 245.81,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13247,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 70.82,,OUTPAT REV HCPCS COMBO 1, 89.33,OTHER, 37.34, 161.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13248,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 70.85,,OUTPAT REV HCPCS COMBO 1, 89.33,OTHER, 37.34, 161.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13249,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 84.46,,OUTPAT REV HCPCS COMBO 1, 108.89,OTHER, 54.48, 192.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13250,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 84.46,,OUTPAT REV HCPCS COMBO 1, 108.89,OTHER, 54.48, 192.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13251,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 61.89,,OUTPAT REV HCPCS COMBO 1, 92.25,OTHER, 61.89, 141.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13252,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 61.89,,OUTPAT REV HCPCS COMBO 1, 92.25,OTHER, 61.89, 141.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13253,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 66.17,,OUTPAT REV HCPCS COMBO 1, 84.04,OTHER, 37.34, 150.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13254,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 66.17,,OUTPAT REV HCPCS COMBO 1, 84.04,OTHER, 37.34, 150.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13255,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 25.59,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13256,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 25.59,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13257,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 129.36,,OUTPAT REV HCPCS COMBO 1, 159.88,OTHER, 54.48, 294.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13258,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 129.36,,OUTPAT REV HCPCS COMBO 1, 159.88,OTHER, 54.48, 294.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13259,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 73.50,,OUTPAT REV HCPCS COMBO 1, 96.44,OTHER, 54.48, 167.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13260,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 73.50,,OUTPAT REV HCPCS COMBO 1, 96.44,OTHER, 54.48, 167.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13261,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 74.18,,OUTPAT REV HCPCS COMBO 1, 110.56,OTHER, 74.18, 169.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13262,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 74.18,,OUTPAT REV HCPCS COMBO 1, 110.56,OTHER, 74.18, 169.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13263,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 37.82,,OUTPAT REV HCPCS COMBO 1, 47.95,OTHER, 21.01, 86.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13264,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 37.82,,OUTPAT REV HCPCS COMBO 1, 47.95,OTHER, 21.01, 86.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13265,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 41.51,,OUTPAT REV HCPCS COMBO 1, 55.33,OTHER, 34.39, 94.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13266,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 41.51,,OUTPAT REV HCPCS COMBO 1, 55.33,OTHER, 34.39, 94.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13267,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.49,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13268,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.49,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13269,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.49,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13270,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 180.60,,OUTPAT REV HCPCS COMBO 1, 142.33,OTHER, 28.82, 411.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13271,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 57.99,,OUTPAT REV HCPCS COMBO 1, 142.33,OTHER, 28.82, 411.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13272,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 57.99,,OUTPAT REV HCPCS COMBO 1, 72.71,OTHER, 28.82, 132.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13273,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 52.84,,OUTPAT REV HCPCS COMBO 1, 74.33,OTHER, 52.80, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13274,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 52.80,,OUTPAT REV HCPCS COMBO 1, 74.33,OTHER, 52.80, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13275,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 52.84,,OUTPAT REV HCPCS COMBO 1, 74.35,OTHER, 52.84, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13276,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 56.36,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13277,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 56.36,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13278,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 56.36,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13279,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 40.91,,OUTPAT REV HCPCS COMBO 1, 60.80,OTHER, 40.91, 93.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13280,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 40.91,,OUTPAT REV HCPCS COMBO 1, 60.80,OTHER, 40.91, 93.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13281,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 29.08,,OUTPAT REV HCPCS COMBO 1, 47.68,OTHER, 29.08, 66.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13282,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 76.97,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13283,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 76.97,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13284,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 76.97,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13285,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 92.45,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13286,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 92.45,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13287,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 92.45,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13288,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 52.75,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13289,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 52.75,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13290,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 52.75,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13291,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 18.92,,OUTPAT REV HCPCS COMBO 1, 30.33,OTHER, 18.92, 43.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13292,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 113.97,,OUTPAT REV HCPCS COMBO 1, 178.52,OTHER, 113.97, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13293,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 135.24,,OUTPAT REV HCPCS COMBO 1, 202.67,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13294,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 128.04,,OUTPAT REV HCPCS COMBO 1, 194.50,OTHER, 128.04, 291.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13295,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 63.79,,OUTPAT REV HCPCS COMBO 1, 106.37,OTHER, 63.79, 145.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13296,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 109.36,,OUTPAT REV HCPCS COMBO 1, 173.75,OTHER, 109.36, 249.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13297,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 115.60,,OUTPAT REV HCPCS COMBO 1, 180.83,OTHER, 115.60, 263.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13298,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 136.43,,OUTPAT REV HCPCS COMBO 1, 204.49,OTHER, 136.43, 310.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13299,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.89,,OUTPAT REV HCPCS COMBO 1, 108.91,OTHER, 65.89, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13300,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 51.91,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13301,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 51.91,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13302,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 51.91,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13303,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 31.56,,OUTPAT REV HCPCS COMBO 1, 44.69,OTHER, 31.56, 71.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13304,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 54.89,,OUTPAT REV HCPCS COMBO 1, 78.22,OTHER, 54.89, 125.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13305,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 54.89,,OUTPAT REV HCPCS COMBO 1, 78.22,OTHER, 54.89, 125.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13306,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 38.11,,OUTPAT REV HCPCS COMBO 1, 59.17,OTHER, 38.11, 86.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13307,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 49.88,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13308,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 49.88,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13309,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 49.88,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13310,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13311,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 61.82,,OUTPAT REV HCPCS COMBO 1, 93.12,OTHER, 61.82, 140.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13312,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 52.03,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 52.03, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13313,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 113.97,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 52.03, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13314,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 53.32,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13315,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 53.32,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13316,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 53.32,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13317,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13318,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13319,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 60.63,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13320,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13321,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 60.63,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13322,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13323,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13324,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 129.00,,OUTPAT REV HCPCS COMBO 1, 192.27,OTHER, 129.00, 294.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13325,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13326,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13327,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 145.27,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13328,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 63.96,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13329,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 63.96,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13330,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 108.39,,OUTPAT REV HCPCS COMBO 1, 161.56,OTHER, 108.39, 247.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13331,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 108.39,,OUTPAT REV HCPCS COMBO 1, 161.56,OTHER, 108.39, 247.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13332,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13333,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13334,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 211.26,,OUTPAT REV HCPCS COMBO 1, 314.88,OTHER, 211.26, 481.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13335,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 211.26,,OUTPAT REV HCPCS COMBO 1, 314.88,OTHER, 211.26, 481.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13336,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 20.47,,OUTPAT REV HCPCS COMBO 1, 30.51,OTHER, 20.47, 46.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13337,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 44.59,,OUTPAT REV HCPCS COMBO 1, 66.46,OTHER, 44.59, 101.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13338,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 44.59,,OUTPAT REV HCPCS COMBO 1, 66.46,OTHER, 44.59, 101.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13339,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 74.56,,OUTPAT REV HCPCS COMBO 1, 111.13,OTHER, 74.56, 169.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13340,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 74.56,,OUTPAT REV HCPCS COMBO 1, 111.13,OTHER, 74.56, 169.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13341,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 110.02,,OUTPAT REV HCPCS COMBO 1, 163.98,OTHER, 110.02, 250.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13342,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 110.02,,OUTPAT REV HCPCS COMBO 1, 163.98,OTHER, 110.02, 250.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13343,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 147.30,,OUTPAT REV HCPCS COMBO 1, 219.55,OTHER, 147.30, 335.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13344,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 147.30,,OUTPAT REV HCPCS COMBO 1, 219.55,OTHER, 147.30, 335.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13345,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13346,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13347,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13348,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13349,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13350,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 115.64,,OUTPAT REV HCPCS COMBO 1, 149.74,OTHER, 77.35, 263.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13351,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 115.64,,OUTPAT REV HCPCS COMBO 1, 149.74,OTHER, 77.35, 263.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13352,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13353,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13354,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 178.88,,OUTPAT REV HCPCS COMBO 1, 233.57,OTHER, 127.82, 407.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13355,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 178.88,,OUTPAT REV HCPCS COMBO 1, 233.57,OTHER, 127.82, 407.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13356,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13357,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13358,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 282.66,,OUTPAT REV HCPCS COMBO 1, 369.55,OTHER, 203.96, 644.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13359,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 282.66,,OUTPAT REV HCPCS COMBO 1, 369.55,OTHER, 203.96, 644.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13360,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13361,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13362,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 443.36,,OUTPAT REV HCPCS COMBO 1, 580.80,OTHER, 324.71, 1010.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13363,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 443.36,,OUTPAT REV HCPCS COMBO 1, 580.80,OTHER, 324.71, 1010.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13364,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13365,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13366,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 739.51,,OUTPAT REV HCPCS COMBO 1, 954.02,OTHER, 479.76, 1685.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13367,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 739.51,,OUTPAT REV HCPCS COMBO 1, 954.02,OTHER, 479.76, 1685.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13368,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13369,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1182.84,,OUTPAT REV HCPCS COMBO 1, 1514.86,OTHER, 720.78, 2695.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13370,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 433.62,,OUTPAT REV HCPCS COMBO 1, 646.30,OTHER, 433.62, 988.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13371,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 19.23,OTHER, 12.90, 29.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13372,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 72.00,,OUTPAT REV HCPCS COMBO 1, 107.32,OTHER, 72.00, 164.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13373,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 72.00,,OUTPAT REV HCPCS COMBO 1, 107.32,OTHER, 72.00, 164.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13374,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 113.31,,OUTPAT REV HCPCS COMBO 1, 167.97,OTHER, 113.31, 258.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13375,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 118.06,,OUTPAT REV HCPCS COMBO 1, 173.37,OTHER, 118.06, 269.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13376,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 123.17,,OUTPAT REV HCPCS COMBO 1, 179.18,OTHER, 123.17, 280.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13377,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 139.26,,OUTPAT REV HCPCS COMBO 1, 197.44,OTHER, 139.26, 317.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13378,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 135.24,,OUTPAT REV HCPCS COMBO 1, 192.88,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13379,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 156.07,,OUTPAT REV HCPCS COMBO 1, 232.62,OTHER, 156.07, 355.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13380,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13381,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 101.97,,OUTPAT REV HCPCS COMBO 1, 155.10,OTHER, 101.97, 232.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13382,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 108.92,,OUTPAT REV HCPCS COMBO 1, 162.99,OTHER, 108.92, 248.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13383,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 118.79,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13384,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 118.79,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13385,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 118.79,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13386,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 121.35,,OUTPAT REV HCPCS COMBO 1, 177.10,OTHER, 121.35, 276.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13387,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 129.39,,OUTPAT REV HCPCS COMBO 1, 192.85,OTHER, 129.39, 294.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13388,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 139.26,,OUTPAT REV HCPCS COMBO 1, 207.56,OTHER, 139.26, 317.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13389,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 37.28,,OUTPAT REV HCPCS COMBO 1, 55.57,OTHER, 37.28, 84.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13390,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 63.96,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13391,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 30.10,,OUTPAT REV HCPCS COMBO 1, 44.86,OTHER, 30.10, 68.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13392,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 114.40,,OUTPAT REV HCPCS COMBO 1, 170.52,OTHER, 114.40, 260.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13393,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 22.74,,OUTPAT REV HCPCS COMBO 1, 33.14,OTHER, 22.74, 51.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13394,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.14,,OUTPAT REV HCPCS COMBO 1, 39.28,OTHER, 28.14, 64.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13395,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 40.58,,OUTPAT REV HCPCS COMBO 1, 60.49,OTHER, 40.58, 92.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13396,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 9.46,,OUTPAT REV HCPCS COMBO 1, 14.10,OTHER, 9.46, 21.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13397,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 9.46,,OUTPAT REV HCPCS COMBO 1, 54.72,OTHER, 9.46, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13398,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 63.96,,OUTPAT REV HCPCS COMBO 1, 54.72,OTHER, 9.46, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13399,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 109.65,,OUTPAT REV HCPCS COMBO 1, 148.65,OTHER, 101.33, 249.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13400,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 118.25,,OUTPAT REV HCPCS COMBO 1, 166.04,OTHER, 118.25, 269.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13401,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 5.48,,OUTPAT REV HCPCS COMBO 1, 8.17,OTHER, 5.48, 12.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13402,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 5.48,,OUTPAT REV HCPCS COMBO 1, 8.17,OTHER, 5.48, 12.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13403,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 165.55,,OUTPAT REV HCPCS COMBO 1, 350.13,OTHER, 165.55, 680.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13404,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 165.55,,OUTPAT REV HCPCS COMBO 1, 350.13,OTHER, 165.55, 680.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13405,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 261.01,,OUTPAT REV HCPCS COMBO 1, 553.11,OTHER, 261.01, 1078.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13406,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 261.01,,OUTPAT REV HCPCS COMBO 1, 553.11,OTHER, 261.01, 1078.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13407,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 152.65,,OUTPAT REV HCPCS COMBO 1, 308.45,OTHER, 152.65, 567.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13408,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 152.65,,OUTPAT REV HCPCS COMBO 1, 308.45,OTHER, 152.65, 567.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13409,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 220.16,,OUTPAT REV HCPCS COMBO 1, 466.19,OTHER, 220.16, 907.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13410,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 220.16,,OUTPAT REV HCPCS COMBO 1, 466.19,OTHER, 220.16, 907.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13411,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 377.54,,OUTPAT REV HCPCS COMBO 1, 562.72,OTHER, 377.54, 860.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13412,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 377.54,,OUTPAT REV HCPCS COMBO 1, 562.72,OTHER, 377.54, 860.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13413,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 419.25,,OUTPAT REV HCPCS COMBO 1, 624.89,OTHER, 419.25, 955.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13414,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 419.25,,OUTPAT REV HCPCS COMBO 1, 624.89,OTHER, 419.25, 955.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13415,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 58.48,,OUTPAT REV HCPCS COMBO 1, 87.16,OTHER, 58.48, 133.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13416,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 27.52,,OUTPAT REV HCPCS COMBO 1, 41.02,OTHER, 27.52, 62.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13417,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13418,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1288.28,,OUTPAT REV HCPCS COMBO 1, 1648.47,OTHER, 779.04, 2936.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13419,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1288.28,,OUTPAT REV HCPCS COMBO 1, 1648.47,OTHER, 779.04, 2936.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13420,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1402.23,,OUTPAT REV HCPCS COMBO 1, 1777.88,OTHER, 779.04, 3195.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13421,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1402.23,,OUTPAT REV HCPCS COMBO 1, 1777.88,OTHER, 779.04, 3195.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13422,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13423,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13424,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13425,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1097.72,OTHER, 508.57, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13426,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1097.72,OTHER, 508.57, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13427,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1162.11,OTHER, 779.04, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13428,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1162.11,OTHER, 779.04, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13429,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 8.23,,OUTPAT REV HCPCS COMBO 1, 9.74,OTHER, 1.66, 18.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13430,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 48.44,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13431,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 11.82,OTHER, 2.58, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13432,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 38.74,,OUTPAT REV HCPCS COMBO 1, 57.75,OTHER, 38.74, 88.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13433,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 20.10,,OUTPAT REV HCPCS COMBO 1, 29.96,OTHER, 20.10, 45.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13434,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 71.08,,OUTPAT REV HCPCS COMBO 1, 88.75,OTHER, 33.71, 162.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13435,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 58.81,OTHER, 33.71, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13436,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 168.13,,OUTPAT REV HCPCS COMBO 1, 250.60,OTHER, 168.13, 383.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13437,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 231.89,OTHER, 165.06, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13438,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 231.89,OTHER, 165.06, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13439,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 18.28,,OUTPAT REV HCPCS COMBO 1, 35.44,OTHER, 18.28, 61.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13440,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 26.32,,OUTPAT REV HCPCS COMBO 1, 44.57,OTHER, 26.32, 61.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13441,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 29.24,,OUTPAT REV HCPCS COMBO 1, 43.58,OTHER, 29.24, 66.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13442,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13443,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 111.71,,OUTPAT REV HCPCS COMBO 1, 166.51,OTHER, 111.71, 254.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13444,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 40.32,,OUTPAT REV HCPCS COMBO 1, 60.10,OTHER, 40.32, 91.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13445,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 3.30,,OUTPAT REV HCPCS COMBO 1, 4.92,OTHER, 3.30, 7.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13446,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 3.20,,OUTPAT REV HCPCS COMBO 1, 4.77,OTHER, 3.20, 7.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13447,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 8.74,,OUTPAT REV HCPCS COMBO 1, 13.02,OTHER, 8.74, 19.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13448,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 90.30,,OUTPAT REV HCPCS COMBO 1, 134.59,OTHER, 90.30, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13449,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .91,,OUTPAT REV HCPCS COMBO 1, 1.36,OTHER, .91, 2.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13450,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1.41,,OUTPAT REV HCPCS COMBO 1, 2.10,OTHER, 1.41, 3.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13451,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 17.38,,OUTPAT REV HCPCS COMBO 1, 25.91,OTHER, 17.38, 39.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13452,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 62.40,,OUTPAT REV HCPCS COMBO 1, 93.00,OTHER, 62.40, 142.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13453,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .98,,OUTPAT REV HCPCS COMBO 1, 1.46,OTHER, .98, 2.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13454,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .69,,OUTPAT REV HCPCS COMBO 1, 1.03,OTHER, .69, 1.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13455,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 3.46,,OUTPAT REV HCPCS COMBO 1, 5.15,OTHER, 3.46, 7.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13456,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 7.69,,OUTPAT REV HCPCS COMBO 1, 11.46,OTHER, 7.69, 17.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13457,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2.94,,OUTPAT REV HCPCS COMBO 1, 4.38,OTHER, 2.94, 6.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13458,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1.72,,OUTPAT REV HCPCS COMBO 1, 2.56,OTHER, 1.72, 3.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13459,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 5.02,,OUTPAT REV HCPCS COMBO 1, 7.91,OTHER, 5.02, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13460,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 5.59,,OUTPAT REV HCPCS COMBO 1, 7.91,OTHER, 5.02, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13461,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 29.38,,OUTPAT REV HCPCS COMBO 1, 43.79,OTHER, 29.38, 66.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13462,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 15.45,,OUTPAT REV HCPCS COMBO 1, 23.02,OTHER, 15.45, 35.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13463,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 4.52,,OUTPAT REV HCPCS COMBO 1, 6.74,OTHER, 4.52, 10.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13464,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 3.49,,OUTPAT REV HCPCS COMBO 1, 5.20,OTHER, 3.49, 7.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13465,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 171.57,,OUTPAT REV HCPCS COMBO 1, 575.18,OTHER, 171.57, 1597.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13466,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 171.57,,OUTPAT REV HCPCS COMBO 1, 690.66,OTHER, 171.57, 2082.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13467,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 171.57,,OUTPAT REV HCPCS COMBO 1, 656.15,OTHER, 171.57, 1937.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13468,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 171.57,,OUTPAT REV HCPCS COMBO 1, 607.70,OTHER, 171.57, 1734.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13469,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 214.57,,OUTPAT REV HCPCS COMBO 1, 735.35,OTHER, 214.57, 2065.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13470,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 367.65,,OUTPAT REV HCPCS COMBO 1, 421.89,OTHER, 18.42, 837.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13471,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2.06,,OUTPAT REV HCPCS COMBO 1, 3.08,OTHER, 2.06, 4.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13472,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13473,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13474,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13475,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13476,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13477,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13478,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13479,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13480,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13481,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13482,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13483,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13484,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13485,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13486,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13487,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13488,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13489,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13490,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13491,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13492,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13493,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13494,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13495,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13496,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13497,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13498,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13499,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13500,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13501,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13502,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13503,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13504,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13505,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13506,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13507,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13508,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.69,,OUTPAT REV HCPCS COMBO 1, 62.01,OTHER, 42.53, 104.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13509,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 49.02,,OUTPAT REV HCPCS COMBO 1, 73.06,OTHER, 49.02, 111.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13510,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13511,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 215.00,,OUTPAT REV HCPCS COMBO 1, 320.46,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13512,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 18.06,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13513,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13514,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 15.05,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13515,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13516,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 11.61,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13517,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13518,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13519,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13520,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13521,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13522,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1.94,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13523,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13524,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13525,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13526,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 79.09,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13527,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13528,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 77.40,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13529,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 24.94,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13530,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 24.94,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13531,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 142.83,,OUTPAT REV HCPCS COMBO 1, 212.89,OTHER, 142.83, 325.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13532,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 52.37,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13533,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13534,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 423.39,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13535,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 308.33,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13536,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 3.87,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13537,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13538,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13539,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13540,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13541,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13542,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13543,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13544,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13545,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13546,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13547,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 43.86,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13548,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 30.89,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13549,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 30.89,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13550,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13551,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 59.16,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13552,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13553,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13554,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13555,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13556,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 7.74,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13557,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 10.32,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13558,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13559,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 12.26,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13560,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 12.26,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13561,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13562,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13563,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13564,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13565,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13566,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13567,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 19.99,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13568,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 4.30,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13569,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 2.02,OTHER, 1.35, 3.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13570,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 215.43,,OUTPAT REV HCPCS COMBO 1, 321.10,OTHER, 215.43, 490.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13571,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 245.96,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13572,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13573,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13574,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13575,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13576,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13577,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13578,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13579,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 14.63,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13580,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 65.44,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13581,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 61.34,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13582,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 40.07,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13583,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 36.78,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13584,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 111.92,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13585,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 3270.45,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13586,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 19.44,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13587,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13588,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13589,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13590,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13591,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13592,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13593,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 1032.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13594,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13595,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13596,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13597,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13598,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13599,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13600,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 602.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13601,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 602.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13602,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 602.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13603,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13604,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13605,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13606,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13607,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13608,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 28.87,,OUTPAT REV HCPCS COMBO 1, 43.03,OTHER, 28.87, 65.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13609,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 4.30,,OUTPAT REV HCPCS COMBO 1, 6.41,OTHER, 4.30, 9.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13610,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2494.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13611,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2064.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13612,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2064.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13613,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, 2064.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13614,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13615,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13616,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13617,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13618,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13619,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13620,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13621,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13622,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13623,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13624,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13625,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13626,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13627,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13628,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13629,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13630,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13631,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13632,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13633,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13634,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13635,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13636,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13637,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13638,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13639,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13640,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13641,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_BCBS,BCBS MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13642,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13643,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13644,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13645,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13646,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13647,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13648,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13649,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13650,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13651,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13652,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13653,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13654,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13655,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13656,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13657,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13658,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13659,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13660,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 209.32,,OUTPAT REV HCPCS COMBO 1, 271.70,OTHER, 142.76, 477.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13661,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 209.32,,OUTPAT REV HCPCS COMBO 1, 271.70,OTHER, 142.76, 477.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13662,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 118.79,,OUTPAT REV HCPCS COMBO 1, 168.89,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13663,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13664,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 211.23,,OUTPAT REV HCPCS COMBO 1, 273.87,OTHER, 142.76, 481.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13665,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13666,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 155.70,,OUTPAT REV HCPCS COMBO 1, 242.16,OTHER, 155.70, 354.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13667,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13668,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13669,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13670,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13671,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13672,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13673,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13674,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13675,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13676,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13677,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13678,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13679,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13680,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13681,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13682,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13683,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13684,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13685,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13686,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13687,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13688,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13689,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13690,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13691,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13692,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13693,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13694,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13695,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13696,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13697,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13698,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13699,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13700,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13701,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13702,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13703,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13704,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13705,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13706,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13707,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13708,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13709,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13710,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 145.30,,OUTPAT REV HCPCS COMBO 1, 185.53,OTHER, 86.20, 331.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13711,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13712,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13713,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13714,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13715,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13716,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13717,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 165.01,,OUTPAT REV HCPCS COMBO 1, 278.63,OTHER, 165.01, 383.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13718,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 296.20,,OUTPAT REV HCPCS COMBO 1, 427.61,OTHER, 296.20, 675.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13719,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 179.25,,OUTPAT REV HCPCS COMBO 1, 237.66,OTHER, 143.26, 408.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13720,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 193.33,,OUTPAT REV HCPCS COMBO 1, 253.66,OTHER, 143.26, 440.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13721,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 209.63,,OUTPAT REV HCPCS COMBO 1, 272.17,OTHER, 143.26, 477.75,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13722,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 191.34,,OUTPAT REV HCPCS COMBO 1, 251.39,OTHER, 143.26, 436.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13723,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13724,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 202.93,,OUTPAT REV HCPCS COMBO 1, 264.56,OTHER, 143.26, 462.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13725,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 204.98,,OUTPAT REV HCPCS COMBO 1, 306.35,OTHER, 204.98, 467.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13726,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13727,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13728,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 230.23,,OUTPAT REV HCPCS COMBO 1, 293.08,OTHER, 132.82, 524.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13729,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 836.72,,OUTPAT REV HCPCS COMBO 1, 1023.77,OTHER, 309.01, 1906.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13730,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13731,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1408.79,,OUTPAT REV HCPCS COMBO 1, 1703.49,OTHER, 435.32, 3210.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13732,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13733,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13734,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13735,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13736,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 145.30,,OUTPAT REV HCPCS COMBO 1, 200.99,OTHER, 145.30, 331.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13737,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13738,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13739,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13740,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13741,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13742,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13743,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13744,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 57.02,,OUTPAT REV HCPCS COMBO 1, 124.43,OTHER, 57.02, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13745,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 53.32,,OUTPAT REV HCPCS COMBO 1, 120.23,OTHER, 53.32, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13746,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 62.14,,OUTPAT REV HCPCS COMBO 1, 130.25,OTHER, 62.14, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13747,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 62.14,,OUTPAT REV HCPCS COMBO 1, 130.25,OTHER, 62.14, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13748,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13749,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13750,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 339.79,,OUTPAT REV HCPCS COMBO 1, 424.57,OTHER, 162.56, 774.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13751,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 260.82,,OUTPAT REV HCPCS COMBO 1, 334.89,OTHER, 162.56, 594.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13752,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 496.58,,OUTPAT REV HCPCS COMBO 1, 675.88,OTHER, 470.23, 1131.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13753,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 406.01,,OUTPAT REV HCPCS COMBO 1, 499.77,OTHER, 162.56, 925.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13754,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 406.01,,OUTPAT REV HCPCS COMBO 1, 499.77,OTHER, 162.56, 925.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13755,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 148.80,,OUTPAT REV HCPCS COMBO 1, 207.69,OTHER, 148.80, 339.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13756,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 148.80,,OUTPAT REV HCPCS COMBO 1, 207.69,OTHER, 148.80, 339.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13757,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 133.93,,OUTPAT REV HCPCS COMBO 1, 176.70,OTHER, 103.34, 305.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13758,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 485.88,,OUTPAT REV HCPCS COMBO 1, 596.69,OTHER, 188.66, 1107.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13759,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 485.88,,OUTPAT REV HCPCS COMBO 1, 596.69,OTHER, 188.66, 1107.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13760,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 845.35,,OUTPAT REV HCPCS COMBO 1, 1089.64,OTHER, 544.52, 1926.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13761,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 15.05,,OUTPAT REV HCPCS COMBO 1, 22.43,OTHER, 15.05, 34.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13762,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13763,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13764,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13765,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13766,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13767,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13768,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 16.02,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13769,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 440.37,,OUTPAT REV HCPCS COMBO 1, 579.04,OTHER, 331.58, 1003.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13770,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13771,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13772,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13773,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13774,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13775,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 124.21,OTHER, 26.22, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13776,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 124.21,OTHER, 26.22, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13777,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13778,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13779,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13780,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13781,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13782,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13783,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13784,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13785,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13786,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13787,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13788,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13789,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 501.48,,OUTPAT REV HCPCS COMBO 1, 718.33,OTHER, 501.48, 1142.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13790,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13791,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13792,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13793,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13794,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13795,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13796,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13797,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13798,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13799,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13800,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13801,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13802,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13803,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13804,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13805,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13806,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13807,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13808,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13809,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13810,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13811,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13812,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13813,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13814,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13815,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 173.27,,OUTPAT REV HCPCS COMBO 1, 242.39,OTHER, 173.27, 394.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13816,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 173.27,,OUTPAT REV HCPCS COMBO 1, 242.39,OTHER, 173.27, 394.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13817,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13818,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 96.75,,OUTPAT REV HCPCS COMBO 1, 199.77,OTHER, 96.75, 377.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13819,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 96.75,,OUTPAT REV HCPCS COMBO 1, 266.50,OTHER, 96.75, 657.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13820,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1478.34,,OUTPAT REV HCPCS COMBO 1, 2146.91,OTHER, 1478.34, 3369.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13821,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1478.34,,OUTPAT REV HCPCS COMBO 1, 2146.91,OTHER, 1478.34, 3369.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13822,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 482.83,,OUTPAT REV HCPCS COMBO 1, 719.65,OTHER, 482.83, 1100.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13823,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 863.68,,OUTPAT REV HCPCS COMBO 1, 1287.31,OTHER, 863.68, 1968.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13824,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 195.18,,OUTPAT REV HCPCS COMBO 1, 290.91,OTHER, 195.18, 444.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13825,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13826,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 112.28,,OUTPAT REV HCPCS COMBO 1, 162.43,OTHER, 112.28, 255.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13827,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 97.21,,OUTPAT REV HCPCS COMBO 1, 145.32,OTHER, 97.21, 221.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13828,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 62.09,,OUTPAT REV HCPCS COMBO 1, 116.13,OTHER, 62.09, 191.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13829,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 76.24,OTHER, 51.17, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13830,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 91.62,,OUTPAT REV HCPCS COMBO 1, 124.60,OTHER, 86.34, 208.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13831,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13832,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13833,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13834,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 58.91,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13835,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13836,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 161.46,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13837,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13838,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13839,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13840,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 122.45,,OUTPAT REV HCPCS COMBO 1, 171.96,OTHER, 122.45, 279.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13841,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13842,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 94.39,,OUTPAT REV HCPCS COMBO 1, 127.74,OTHER, 86.34, 215.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13843,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13844,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 137.97,,OUTPAT REV HCPCS COMBO 1, 189.58,OTHER, 137.97, 314.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13845,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13846,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 84.85,,OUTPAT REV HCPCS COMBO 1, 116.92,OTHER, 84.85, 193.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13847,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13848,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 234.79,,OUTPAT REV HCPCS COMBO 1, 299.54,OTHER, 138.19, 535.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13849,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13850,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 165.67,,OUTPAT REV HCPCS COMBO 1, 221.04,OTHER, 138.19, 377.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13851,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13852,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 127.28,,OUTPAT REV HCPCS COMBO 1, 177.44,OTHER, 127.28, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13853,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13854,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 44.60,,OUTPAT REV HCPCS COMBO 1, 71.21,OTHER, 44.60, 101.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13855,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13856,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 152.34,,OUTPAT REV HCPCS COMBO 1, 193.56,OTHER, 86.34, 347.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13857,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13858,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 178.71,,OUTPAT REV HCPCS COMBO 1, 223.50,OTHER, 86.34, 407.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13859,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1259.10,,OUTPAT REV HCPCS COMBO 1, 1313.91,OTHER, 283.82, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13860,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 935.89,,OUTPAT REV HCPCS COMBO 1, 1313.91,OTHER, 283.82, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13861,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13862,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13863,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 962.60,,OUTPAT REV HCPCS COMBO 1, 1196.04,OTHER, 432.18, 2193.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13864,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 962.60,,OUTPAT REV HCPCS COMBO 1, 1196.04,OTHER, 432.18, 2193.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13865,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13866,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13867,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1259.10,,OUTPAT REV HCPCS COMBO 1, 1545.39,OTHER, 485.27, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13868,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1259.10,,OUTPAT REV HCPCS COMBO 1, 1545.39,OTHER, 485.27, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13869,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13870,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13871,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 781.62,,OUTPAT REV HCPCS COMBO 1, 955.20,OTHER, 283.82, 1781.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13872,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13873,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 518.18,,OUTPAT REV HCPCS COMBO 1, 691.35,OTHER, 432.18, 1180.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13874,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13875,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 679.40,,OUTPAT REV HCPCS COMBO 1, 887.08,OTHER, 485.27, 1548.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13876,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13877,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 734.01,,OUTPAT REV HCPCS COMBO 1, 901.22,OTHER, 283.82, 1673.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13878,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 734.17,,OUTPAT REV HCPCS COMBO 1, 901.22,OTHER, 283.82, 1673.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13879,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13880,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13881,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 839.22,,OUTPAT REV HCPCS COMBO 1, 1055.93,OTHER, 432.18, 1912.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13882,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1056.51,,OUTPAT REV HCPCS COMBO 1, 1302.68,OTHER, 432.18, 2407.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13883,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13884,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13885,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 350.02,,OUTPAT REV HCPCS COMBO 1, 513.03,OTHER, 350.02, 797.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13886,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13887,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1076.96,,OUTPAT REV HCPCS COMBO 1, 1290.59,OTHER, 283.82, 2454.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13888,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13889,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1120.02,,OUTPAT REV HCPCS COMBO 1, 1374.81,OTHER, 432.18, 2552.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13890,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13891,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1013.04,,OUTPAT REV HCPCS COMBO 1, 1265.96,OTHER, 485.27, 2308.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13892,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13893,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 843.77,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13894,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 843.77,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13895,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 843.77,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13896,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13897,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13898,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13899,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1015.19,,OUTPAT REV HCPCS COMBO 1, 1270.81,OTHER, 495.38, 2313.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13900,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13901,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1317.38,,OUTPAT REV HCPCS COMBO 1, 1681.52,OTHER, 779.04, 3002.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13902,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13903,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 971.97,,OUTPAT REV HCPCS COMBO 1, 1224.87,OTHER, 508.57, 2215.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13904,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13905,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1036.73,,OUTPAT REV HCPCS COMBO 1, 1324.21,OTHER, 616.91, 2362.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13906,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13907,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1186.59,,OUTPAT REV HCPCS COMBO 1, 1532.99,OTHER, 779.04, 2704.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13908,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13909,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 979.65,,OUTPAT REV HCPCS COMBO 1, 1233.59,OTHER, 508.57, 2232.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13910,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13911,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 976.96,,OUTPAT REV HCPCS COMBO 1, 1256.33,OTHER, 616.91, 2226.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13912,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13913,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1123.27,,OUTPAT REV HCPCS COMBO 1, 1461.09,OTHER, 779.04, 2560.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13914,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13915,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1138.21,,OUTPAT REV HCPCS COMBO 1, 1413.66,OTHER, 508.57, 2594.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13916,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13917,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1757.38,,OUTPAT REV HCPCS COMBO 1, 2181.19,OTHER, 779.04, 4005.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13918,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1757.38,,OUTPAT REV HCPCS COMBO 1, 2181.19,OTHER, 779.04, 4005.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13919,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13920,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13921,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13922,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13923,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13924,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13925,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13926,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13927,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13928,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13929,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13930,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13931,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13932,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13933,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13934,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13935,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 195.04,,OUTPAT REV HCPCS COMBO 1, 242.05,OTHER, 86.34, 444.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13936,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 196.33,,OUTPAT REV HCPCS COMBO 1, 243.52,OTHER, 86.34, 447.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13937,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13938,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13939,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 159.59,,OUTPAT REV HCPCS COMBO 1, 214.14,OTHER, 138.19, 363.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13940,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 182.39,,OUTPAT REV HCPCS COMBO 1, 240.03,OTHER, 138.19, 415.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13941,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13942,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13943,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 190.18,,OUTPAT REV HCPCS COMBO 1, 248.87,OTHER, 138.19, 433.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13944,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13945,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 127.28,,OUTPAT REV HCPCS COMBO 1, 165.10,OTHER, 86.34, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13946,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13947,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13948,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13949,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13950,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13951,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13952,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13953,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13954,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1356.87,OTHER, 432.18, 2737.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13955,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1201.21,,OUTPAT REV HCPCS COMBO 1, 1356.87,OTHER, 432.18, 2737.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13956,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13957,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1498.49,,OUTPAT REV HCPCS COMBO 1, 1817.25,OTHER, 485.27, 3415.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13958,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13959,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13960,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13961,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13962,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13963,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13964,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13965,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2141.41,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13966,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13967,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13968,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13969,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13970,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13971,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13972,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13973,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13974,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 544.38,,OUTPAT REV HCPCS COMBO 1, 1310.99,OTHER, 544.38, 2768.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13975,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1214.75,,OUTPAT REV HCPCS COMBO 1, 1310.99,OTHER, 544.38, 2768.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13976,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13977,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13978,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 130.72,,OUTPAT REV HCPCS COMBO 1, 169.01,OTHER, 86.34, 297.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13979,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 130.72,,OUTPAT REV HCPCS COMBO 1, 169.01,OTHER, 86.34, 297.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13980,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13981,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13982,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 189.11,,OUTPAT REV HCPCS COMBO 1, 247.65,OTHER, 138.19, 430.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13983,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13984,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 279.76,,OUTPAT REV HCPCS COMBO 1, 350.60,OTHER, 138.19, 637.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13985,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13986,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 307.96,,OUTPAT REV HCPCS COMBO 1, 382.63,OTHER, 138.19, 701.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13987,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13988,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 229.47,,OUTPAT REV HCPCS COMBO 1, 293.50,OTHER, 138.19, 522.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13989,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13990,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 205.14,,OUTPAT REV HCPCS COMBO 1, 265.86,OTHER, 138.19, 467.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13991,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13992,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 161.46,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13993,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13994,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 107.50,,OUTPAT REV HCPCS COMBO 1, 142.64,OTHER, 86.34, 245.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13995,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13996,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.06,OTHER, 36.98, 88.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13997,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 163.44,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 13998,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 13999,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 199.31,,OUTPAT REV HCPCS COMBO 1, 259.24,OTHER, 138.19, 454.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14000,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14001,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 118.00,,OUTPAT REV HCPCS COMBO 1, 166.91,OTHER, 118.00, 268.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14002,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14003,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 329.50,,OUTPAT REV HCPCS COMBO 1, 407.08,OTHER, 138.19, 750.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14004,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14005,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1225.59,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14006,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1225.59,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14007,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1225.59,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14008,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14009,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14010,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14011,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 483.75,,OUTPAT REV HCPCS COMBO 1, 664.89,OTHER, 483.75, 1102.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14012,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14013,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1392.67,,OUTPAT REV HCPCS COMBO 1, 1649.11,OTHER, 283.82, 3173.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14014,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1392.67,,OUTPAT REV HCPCS COMBO 1, 1649.11,OTHER, 283.82, 3173.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14015,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14016,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14017,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1376.00,,OUTPAT REV HCPCS COMBO 1, 1665.51,OTHER, 432.18, 3136.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14018,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14019,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1207.81,,OUTPAT REV HCPCS COMBO 1, 1439.18,OTHER, 283.82, 2752.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14020,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14021,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1364.62,,OUTPAT REV HCPCS COMBO 1, 1652.58,OTHER, 432.18, 3110.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14022,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14023,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1290.00,,OUTPAT REV HCPCS COMBO 1, 1580.48,OTHER, 485.27, 2940.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14024,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14025,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1401.19,,OUTPAT REV HCPCS COMBO 1, 1712.29,OTHER, 508.57, 3193.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14026,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14027,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1561.88,,OUTPAT REV HCPCS COMBO 1, 1894.78,OTHER, 508.57, 3559.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14028,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14029,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1370.93,,OUTPAT REV HCPCS COMBO 1, 1677.93,OTHER, 508.57, 3124.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14030,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14031,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1703.32,,OUTPAT REV HCPCS COMBO 1, 2119.80,OTHER, 779.04, 3881.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14032,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14033,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2072.93,,OUTPAT REV HCPCS COMBO 1, 2539.54,OTHER, 779.04, 4724.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14034,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14035,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1941.42,,OUTPAT REV HCPCS COMBO 1, 2390.20,OTHER, 779.04, 4424.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14036,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14037,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14038,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14039,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14040,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 179.56,,OUTPAT REV HCPCS COMBO 1, 236.81,OTHER, 138.19, 409.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14041,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14042,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 141.74,,OUTPAT REV HCPCS COMBO 1, 193.87,OTHER, 138.19, 323.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14043,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14044,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1051.04,,OUTPAT REV HCPCS COMBO 1, 1261.16,OTHER, 283.82, 2395.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14045,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1051.04,,OUTPAT REV HCPCS COMBO 1, 1261.16,OTHER, 283.82, 2395.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14046,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14047,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14048,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1015.49,,OUTPAT REV HCPCS COMBO 1, 1256.10,OTHER, 432.18, 2314.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14049,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14050,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 686.07,,OUTPAT REV HCPCS COMBO 1, 894.65,OTHER, 485.27, 1563.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14051,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14052,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1435.73,,OUTPAT REV HCPCS COMBO 1, 1751.53,OTHER, 508.57, 3272.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14053,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14054,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2152.02,,OUTPAT REV HCPCS COMBO 1, 2629.35,OTHER, 779.04, 4904.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14055,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14056,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14057,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14058,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14059,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14060,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14061,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14062,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 126.48,,OUTPAT REV HCPCS COMBO 1, 164.19,OTHER, 86.34, 288.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14063,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14064,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 179.46,,OUTPAT REV HCPCS COMBO 1, 224.35,OTHER, 86.34, 408.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14065,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14066,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 165.68,,OUTPAT REV HCPCS COMBO 1, 208.71,OTHER, 86.34, 377.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14067,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 165.68,,OUTPAT REV HCPCS COMBO 1, 208.71,OTHER, 86.34, 377.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14068,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 171.85,,OUTPAT REV HCPCS COMBO 1, 215.71,OTHER, 86.34, 391.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14069,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14070,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14071,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14072,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14073,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14074,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14075,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14076,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14077,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14078,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 136.74,,OUTPAT REV HCPCS COMBO 1, 175.84,OTHER, 86.34, 311.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14079,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 130.77,,OUTPAT REV HCPCS COMBO 1, 169.06,OTHER, 86.34, 298.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14080,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 130.77,,OUTPAT REV HCPCS COMBO 1, 169.06,OTHER, 86.34, 298.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14081,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14082,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14083,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14084,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 178.02,,OUTPAT REV HCPCS COMBO 1, 235.06,OTHER, 138.19, 405.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14085,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 178.02,,OUTPAT REV HCPCS COMBO 1, 235.06,OTHER, 138.19, 405.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14086,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 182.68,,OUTPAT REV HCPCS COMBO 1, 240.36,OTHER, 138.19, 416.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14087,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14088,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14089,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14090,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 175.36,,OUTPAT REV HCPCS COMBO 1, 219.70,OTHER, 86.34, 399.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14091,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 170.74,,OUTPAT REV HCPCS COMBO 1, 214.45,OTHER, 86.34, 389.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14092,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 170.74,,OUTPAT REV HCPCS COMBO 1, 214.45,OTHER, 86.34, 389.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14093,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14094,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14095,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14096,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 163.79,,OUTPAT REV HCPCS COMBO 1, 206.56,OTHER, 86.34, 373.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14097,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 168.41,,OUTPAT REV HCPCS COMBO 1, 211.81,OTHER, 86.34, 383.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14098,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 163.79,,OUTPAT REV HCPCS COMBO 1, 206.56,OTHER, 86.34, 373.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14099,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14100,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14101,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14102,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 184.47,,OUTPAT REV HCPCS COMBO 1, 230.04,OTHER, 86.34, 420.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14103,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 178.71,,OUTPAT REV HCPCS COMBO 1, 223.50,OTHER, 86.34, 407.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14104,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14105,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14106,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14107,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 185.16,,OUTPAT REV HCPCS COMBO 1, 230.83,OTHER, 86.34, 421.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14108,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 185.16,,OUTPAT REV HCPCS COMBO 1, 230.83,OTHER, 86.34, 421.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14109,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 190.92,,OUTPAT REV HCPCS COMBO 1, 237.37,OTHER, 86.34, 435.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14110,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14111,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14112,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14113,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 58.91,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14114,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 81.70,,OUTPAT REV HCPCS COMBO 1, 125.68,OTHER, 81.70, 186.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14115,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 58.91,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14116,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14117,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14118,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14119,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 170.11,,OUTPAT REV HCPCS COMBO 1, 213.73,OTHER, 86.34, 387.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14120,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 164.82,,OUTPAT REV HCPCS COMBO 1, 207.73,OTHER, 86.34, 375.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14121,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 164.83,,OUTPAT REV HCPCS COMBO 1, 207.74,OTHER, 86.34, 375.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14122,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14123,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14124,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14125,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 191.64,,OUTPAT REV HCPCS COMBO 1, 238.18,OTHER, 86.34, 436.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14126,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 196.26,,OUTPAT REV HCPCS COMBO 1, 243.44,OTHER, 86.34, 447.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14127,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 191.64,,OUTPAT REV HCPCS COMBO 1, 238.18,OTHER, 86.34, 436.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14128,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14129,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14130,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14131,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 181.03,,OUTPAT REV HCPCS COMBO 1, 238.48,OTHER, 138.19, 412.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14132,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 175.27,,OUTPAT REV HCPCS COMBO 1, 231.94,OTHER, 138.19, 399.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14133,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 175.27,,OUTPAT REV HCPCS COMBO 1, 231.94,OTHER, 138.19, 399.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14134,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14135,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14136,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14137,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 175.94,,OUTPAT REV HCPCS COMBO 1, 220.36,OTHER, 86.34, 400.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14138,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 175.99,,OUTPAT REV HCPCS COMBO 1, 220.42,OTHER, 86.34, 401.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14139,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 180.62,,OUTPAT REV HCPCS COMBO 1, 225.67,OTHER, 86.34, 411.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14140,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14141,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14142,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14143,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 146.59,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14144,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 135.73,,OUTPAT REV HCPCS COMBO 1, 174.69,OTHER, 86.34, 309.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14145,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14146,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14147,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14148,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14149,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14150,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14151,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14152,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14153,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14154,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14155,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14156,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14157,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14158,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14159,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14160,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14161,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14162,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14163,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14164,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14165,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14166,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14167,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14168,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14169,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 813.42,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14170,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 1061.06,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14171,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14172,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14173,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14174,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14175,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14176,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 287.67,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14177,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 287.67,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14178,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14179,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14180,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 287.67,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14181,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14182,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14183,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 813.42,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14184,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14185,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14186,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14187,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14188,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14189,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14190,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14191,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14192,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14193,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14194,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14195,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14196,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14197,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14198,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1216.47,,OUTPAT REV HCPCS COMBO 1, 1484.34,OTHER, 432.18, 2772.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14199,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1216.47,,OUTPAT REV HCPCS COMBO 1, 1484.34,OTHER, 432.18, 2772.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14200,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14201,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14202,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14203,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14204,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14205,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14206,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14207,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 822.87,,OUTPAT REV HCPCS COMBO 1, 1055.55,OTHER, 508.57, 1875.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14208,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14209,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1419.11,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14210,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1419.11,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14211,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1419.11,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14212,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14213,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14214,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14215,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14216,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14217,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14218,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14219,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14220,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14221,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14222,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14223,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14224,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14225,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14226,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14227,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14228,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14229,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14230,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14231,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14232,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14233,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14234,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14235,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14236,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14237,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14238,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14239,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14240,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14241,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14242,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14243,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14244,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14245,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14246,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14247,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1113.81,,OUTPAT REV HCPCS COMBO 1, 1450.34,OTHER, 779.04, 2538.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14248,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1113.81,,OUTPAT REV HCPCS COMBO 1, 1450.34,OTHER, 779.04, 2538.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14249,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14250,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14251,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14252,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14253,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14254,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14255,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 154.92,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14256,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 154.92,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14257,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 154.92,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14258,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14259,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14260,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14261,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14262,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14263,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14264,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14265,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14266,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14267,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14268,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14269,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14270,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 195.73,,OUTPAT REV HCPCS COMBO 1, 234.40,OTHER, 146.51, 446.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14271,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 155.65,,OUTPAT REV HCPCS COMBO 1, 234.40,OTHER, 146.51, 446.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14272,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14273,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14274,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 160.19,,OUTPAT REV HCPCS COMBO 1, 202.98,OTHER, 88.46, 365.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14275,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 160.19,,OUTPAT REV HCPCS COMBO 1, 202.98,OTHER, 88.46, 365.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14276,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 164.81,,OUTPAT REV HCPCS COMBO 1, 208.23,OTHER, 88.46, 375.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14277,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14278,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14279,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14280,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 167.46,,OUTPAT REV HCPCS COMBO 1, 210.73,OTHER, 86.34, 381.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14281,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 162.18,,OUTPAT REV HCPCS COMBO 1, 204.73,OTHER, 86.34, 369.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14282,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 162.18,,OUTPAT REV HCPCS COMBO 1, 204.73,OTHER, 86.34, 369.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14283,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14284,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14285,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14286,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 208.05,,OUTPAT REV HCPCS COMBO 1, 269.16,OTHER, 138.19, 474.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14287,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 212.67,,OUTPAT REV HCPCS COMBO 1, 274.41,OTHER, 138.19, 484.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14288,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 208.05,,OUTPAT REV HCPCS COMBO 1, 269.16,OTHER, 138.19, 474.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14289,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14290,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14291,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14292,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 325.08,,OUTPAT REV HCPCS COMBO 1, 402.07,OTHER, 138.19, 740.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14293,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 319.17,,OUTPAT REV HCPCS COMBO 1, 395.36,OTHER, 138.19, 727.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14294,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 319.17,,OUTPAT REV HCPCS COMBO 1, 395.36,OTHER, 138.19, 727.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14295,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14296,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14297,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14298,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 116.95,,OUTPAT REV HCPCS COMBO 1, 153.37,OTHER, 86.34, 266.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14299,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14300,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 195.94,,OUTPAT REV HCPCS COMBO 1, 243.07,OTHER, 86.34, 446.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14301,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 191.32,,OUTPAT REV HCPCS COMBO 1, 237.82,OTHER, 86.34, 436.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14302,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 191.32,,OUTPAT REV HCPCS COMBO 1, 237.82,OTHER, 86.34, 436.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14303,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14304,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14305,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14306,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 74.90,OTHER, 36.98, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14307,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 74.90,OTHER, 36.98, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14308,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 73.96,,OUTPAT REV HCPCS COMBO 1, 116.89,OTHER, 73.96, 168.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14309,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14310,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14311,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14312,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 163.83,,OUTPAT REV HCPCS COMBO 1, 218.95,OTHER, 138.19, 373.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14313,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 163.83,,OUTPAT REV HCPCS COMBO 1, 218.95,OTHER, 138.19, 373.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14314,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 169.42,,OUTPAT REV HCPCS COMBO 1, 225.30,OTHER, 138.19, 386.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14315,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14316,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14317,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14318,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 185.33,,OUTPAT REV HCPCS COMBO 1, 243.37,OTHER, 138.19, 422.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14319,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 179.52,,OUTPAT REV HCPCS COMBO 1, 236.76,OTHER, 138.19, 409.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14320,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 179.52,,OUTPAT REV HCPCS COMBO 1, 236.76,OTHER, 138.19, 409.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14321,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14322,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14323,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14324,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 146.18,,OUTPAT REV HCPCS COMBO 1, 186.56,OTHER, 86.34, 333.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14325,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 146.18,,OUTPAT REV HCPCS COMBO 1, 186.56,OTHER, 86.34, 333.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14326,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14327,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14328,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 202.21,,OUTPAT REV HCPCS COMBO 1, 250.19,OTHER, 86.34, 460.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14329,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 197.50,,OUTPAT REV HCPCS COMBO 1, 244.84,OTHER, 86.34, 450.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14330,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 197.59,,OUTPAT REV HCPCS COMBO 1, 244.94,OTHER, 86.34, 450.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14331,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14332,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14333,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14334,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 100.19,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14335,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 100.19,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14336,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 100.19,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14337,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14338,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14339,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14340,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14341,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14342,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14343,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14344,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14345,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14346,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14347,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14348,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 139.75,,OUTPAT REV HCPCS COMBO 1, 179.26,OTHER, 86.34, 318.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14349,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14350,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14351,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14352,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14353,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14354,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14355,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14356,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14357,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14358,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14359,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14360,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14361,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14362,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14363,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14364,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14365,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 991.15,,OUTPAT REV HCPCS COMBO 1, 1193.14,OTHER, 283.82, 2258.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14366,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14367,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14368,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14369,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14370,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14371,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14372,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14373,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14374,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14375,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14376,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14377,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14378,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14379,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14380,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14381,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14382,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14383,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14384,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14385,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14386,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14387,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14388,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14389,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14390,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1173.04,,OUTPAT REV HCPCS COMBO 1, 1435.02,OTHER, 432.18, 2673.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14391,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1167.20,,OUTPAT REV HCPCS COMBO 1, 1428.39,OTHER, 432.18, 2660.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14392,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1167.20,,OUTPAT REV HCPCS COMBO 1, 1428.39,OTHER, 432.18, 2660.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14393,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14394,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14395,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14396,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14397,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14398,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14399,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14400,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14401,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14402,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 597.27,,OUTPAT REV HCPCS COMBO 1, 796.22,OTHER, 495.38, 1361.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14403,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 597.27,,OUTPAT REV HCPCS COMBO 1, 796.22,OTHER, 495.38, 1361.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14404,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14405,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14406,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14407,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14408,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14409,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14410,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14411,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14412,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14413,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14414,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14415,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14416,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14417,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14418,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1556.76,,OUTPAT REV HCPCS COMBO 1, 1953.37,OTHER, 779.04, 3547.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14419,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1556.76,,OUTPAT REV HCPCS COMBO 1, 1953.37,OTHER, 779.04, 3547.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14420,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14421,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14422,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14423,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14424,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1356.11,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14425,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1356.11,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14426,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14427,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14428,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14429,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14430,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14431,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14432,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14433,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14434,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14435,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14436,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14437,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14438,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14439,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14440,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14441,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14442,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14443,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14444,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14445,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14446,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14447,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14448,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14449,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14450,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14451,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14452,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1227.35,OTHER, 786.90, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14453,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1323.48,OTHER, 786.90, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14454,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1474.10,OTHER, 989.00, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14455,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 786.90,,OUTPAT REV HCPCS COMBO 1, 1227.35,OTHER, 786.90, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14456,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 786.90,,OUTPAT REV HCPCS COMBO 1, 1323.48,OTHER, 786.90, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14457,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14458,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14459,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14460,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14461,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14462,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 71.38,,OUTPAT REV HCPCS COMBO 1, 102.58,OTHER, 71.38, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14463,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 71.38,,OUTPAT REV HCPCS COMBO 1, 102.58,OTHER, 71.38, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14464,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14465,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14466,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 83.13,OTHER, 36.98, 172.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14467,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14468,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 254.96,,OUTPAT REV HCPCS COMBO 1, 322.43,OTHER, 138.19, 581.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14469,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 254.96,,OUTPAT REV HCPCS COMBO 1, 322.43,OTHER, 138.19, 581.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14470,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14471,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14472,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1125.78,,OUTPAT REV HCPCS COMBO 1, 1346.03,OTHER, 283.82, 2565.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14473,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14474,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1269.20,,OUTPAT REV HCPCS COMBO 1, 1544.22,OTHER, 432.18, 2892.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14475,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14476,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1433.28,,OUTPAT REV HCPCS COMBO 1, 1743.20,OTHER, 485.27, 3266.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14477,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14478,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2571.41,,OUTPAT REV HCPCS COMBO 1, 3113.75,OTHER, 813.20, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14479,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14480,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1431.39,,OUTPAT REV HCPCS COMBO 1, 1743.46,OTHER, 495.38, 3262.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14481,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14482,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2239.96,,OUTPAT REV HCPCS COMBO 1, 2609.45,OTHER, 276.02, 5105.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14483,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2239.96,,OUTPAT REV HCPCS COMBO 1, 2609.45,OTHER, 276.02, 5105.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14484,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14485,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14486,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2571.41,,OUTPAT REV HCPCS COMBO 1, 3021.78,OTHER, 426.91, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14487,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2571.41,,OUTPAT REV HCPCS COMBO 1, 3021.78,OTHER, 426.91, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14488,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14489,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14490,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2881.09,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14491,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2881.09,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14492,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2881.09,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14493,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14494,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14495,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14496,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1381.27,,OUTPAT REV HCPCS COMBO 1, 1689.68,OTHER, 508.57, 3148.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14497,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1381.27,,OUTPAT REV HCPCS COMBO 1, 1689.68,OTHER, 508.57, 3148.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14498,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14499,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14500,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1454.34,,OUTPAT REV HCPCS COMBO 1, 1837.06,OTHER, 779.04, 3314.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14501,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14502,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1075.00,,OUTPAT REV HCPCS COMBO 1, 2098.35,OTHER, 1075.00, 3967.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14503,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1740.64,,OUTPAT REV HCPCS COMBO 1, 2098.35,OTHER, 1075.00, 3967.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14504,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14505,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14506,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14507,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 300.14,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14508,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 300.14,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14509,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 300.14,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14510,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14511,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14512,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 472.37,,OUTPAT REV HCPCS COMBO 1, 704.06,OTHER, 472.37, 1076.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14513,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14514,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 166.15,,OUTPAT REV HCPCS COMBO 1, 248.14,OTHER, 166.15, 378.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14515,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14516,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 326.19,,OUTPAT REV HCPCS COMBO 1, 429.88,OTHER, 249.71, 743.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14517,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14518,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1213.11,,OUTPAT REV HCPCS COMBO 1, 1495.57,OTHER, 495.38, 2764.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14519,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1213.11,,OUTPAT REV HCPCS COMBO 1, 1495.57,OTHER, 495.38, 2764.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14520,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14521,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14522,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 150.50,,OUTPAT REV HCPCS COMBO 1, 224.32,OTHER, 150.50, 343.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14523,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14524,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 309.81,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14525,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 309.81,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14526,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 309.81,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14527,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14528,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14529,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14530,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 233.31,,OUTPAT REV HCPCS COMBO 1, 286.59,OTHER, 90.89, 531.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14531,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14532,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 219.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14533,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 219.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14534,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 219.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14535,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 225.75,,OUTPAT REV HCPCS COMBO 1, 288.12,OTHER, 133.37, 514.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14536,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14537,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14538,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14539,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14540,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 413.68,,OUTPAT REV HCPCS COMBO 1, 503.49,OTHER, 141.55, 942.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14541,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14542,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14543,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14544,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14545,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14546,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14547,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14548,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14549,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14550,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14551,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14552,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 468.07,OTHER, 163.97, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14553,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14554,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14555,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14556,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14557,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14558,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 335.33,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14559,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14560,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14561,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14562,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14563,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14564,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 335.33,,OUTPAT REV HCPCS COMBO 1, 414.50,OTHER, 141.55, 764.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14565,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14566,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 161.25,,OUTPAT REV HCPCS COMBO 1, 214.87,OTHER, 133.37, 367.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14567,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14568,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 330.24,,OUTPAT REV HCPCS COMBO 1, 408.73,OTHER, 141.55, 752.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14569,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14570,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 417.26,,OUTPAT REV HCPCS COMBO 1, 507.55,OTHER, 141.55, 950.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14571,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14572,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 663.92,,OUTPAT REV HCPCS COMBO 1, 775.60,OTHER, 90.89, 1513.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14573,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14574,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 227.90,,OUTPAT REV HCPCS COMBO 1, 290.56,OTHER, 133.37, 519.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14575,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14576,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 339.97,,OUTPAT REV HCPCS COMBO 1, 419.77,OTHER, 141.55, 774.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14577,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14578,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 385.59,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14579,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 385.59,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14580,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 385.59,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14581,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14582,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14583,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14584,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 269.07,,OUTPAT REV HCPCS COMBO 1, 322.12,OTHER, 90.89, 613.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14585,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 260.12,,OUTPAT REV HCPCS COMBO 1, 322.12,OTHER, 90.89, 613.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14586,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14587,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14588,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 330.02,,OUTPAT REV HCPCS COMBO 1, 408.48,OTHER, 141.55, 752.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14589,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14590,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 688.00,,OUTPAT REV HCPCS COMBO 1, 813.95,OTHER, 137.10, 1568.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14591,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 435.01,,OUTPAT REV HCPCS COMBO 1, 526.64,OTHER, 137.10, 991.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14592,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 435.01,,OUTPAT REV HCPCS COMBO 1, 526.64,OTHER, 137.10, 991.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14593,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14594,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14595,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14596,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14597,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 236.50,,OUTPAT REV HCPCS COMBO 1, 300.33,OTHER, 133.37, 539.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14598,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14599,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14600,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14601,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14602,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14603,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14604,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14605,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14606,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14607,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14608,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14609,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14610,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14611,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14612,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14613,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14614,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 285.90,,OUTPAT REV HCPCS COMBO 1, 426.14,OTHER, 285.90, 651.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14615,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14616,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 182.57,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14617,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 182.57,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14618,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 182.57,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14619,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14620,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14621,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14622,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14623,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 186.51,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14624,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 186.51,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14625,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 61.06,,OUTPAT REV HCPCS COMBO 1, 91.01,OTHER, 61.06, 139.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14626,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 21.15,,OUTPAT REV HCPCS COMBO 1, 78.82,OTHER, 21.15, 181.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14627,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14628,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14629,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14630,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14631,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14632,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14633,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14634,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14635,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 210.70,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14636,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 175.87,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14637,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 210.70,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14638,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14639,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14640,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14641,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14642,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14643,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14644,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14645,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14646,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14647,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14648,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14649,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14650,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14651,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14652,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14653,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14654,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 73.53,,OUTPAT REV HCPCS COMBO 1, 116.40,OTHER, 73.53, 167.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14655,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14656,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 315.98,,OUTPAT REV HCPCS COMBO 1, 414.07,OTHER, 232.03, 720.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14657,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 84.28,,OUTPAT REV HCPCS COMBO 1, 158.67,OTHER, 84.28, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14658,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 150.93,,OUTPAT REV HCPCS COMBO 1, 158.67,OTHER, 84.28, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14659,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14660,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14661,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 127.28,,OUTPAT REV HCPCS COMBO 1, 154.63,OTHER, 42.36, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14662,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 150.93,,OUTPAT REV HCPCS COMBO 1, 204.30,OTHER, 138.19, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14663,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14664,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 549.04,,OUTPAT REV HCPCS COMBO 1, 660.83,OTHER, 156.82, 1251.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14665,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 549.04,,OUTPAT REV HCPCS COMBO 1, 660.83,OTHER, 156.82, 1251.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14666,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14667,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14668,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 426.80,,OUTPAT REV HCPCS COMBO 1, 533.81,OTHER, 206.35, 972.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14669,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 426.80,,OUTPAT REV HCPCS COMBO 1, 533.81,OTHER, 206.35, 972.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14670,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14671,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14672,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 600.24,,OUTPAT REV HCPCS COMBO 1, 757.92,OTHER, 320.35, 1367.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14673,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14674,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 724.72,,OUTPAT REV HCPCS COMBO 1, 899.81,OTHER, 322.62, 1651.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14675,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14676,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 847.10,,OUTPAT REV HCPCS COMBO 1, 1092.65,OTHER, 548.80, 1930.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14677,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14678,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 672.15,,OUTPAT REV HCPCS COMBO 1, 864.03,OTHER, 423.08, 1531.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14679,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14680,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 215.00,,OUTPAT REV HCPCS COMBO 1, 344.89,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14681,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14682,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 645.00,,OUTPAT REV HCPCS COMBO 1, 830.31,OTHER, 410.92, 1470.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14683,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14684,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 885.80,,OUTPAT REV HCPCS COMBO 1, 1103.77,OTHER, 410.92, 2018.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14685,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14686,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1111.16,OTHER, 359.95, 2058.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14687,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14688,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 474.08,,OUTPAT REV HCPCS COMBO 1, 624.07,OTHER, 359.95, 1080.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14689,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14690,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 516.57,,OUTPAT REV HCPCS COMBO 1, 672.34,OTHER, 360.01, 1177.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14691,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14692,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 417.10,,OUTPAT REV HCPCS COMBO 1, 559.38,OTHER, 360.01, 950.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14693,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14694,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1005.92,,OUTPAT REV HCPCS COMBO 1, 1228.06,OTHER, 360.01, 2292.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14695,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14696,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1064.04,,OUTPAT REV HCPCS COMBO 1, 1294.05,OTHER, 360.01, 2425.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14697,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14698,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 470.85,,OUTPAT REV HCPCS COMBO 1, 701.80,OTHER, 470.85, 1073.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14699,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14700,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 775.51,,OUTPAT REV HCPCS COMBO 1, 1149.19,OTHER, 775.51, 1767.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14701,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 775.51,,OUTPAT REV HCPCS COMBO 1, 1149.19,OTHER, 775.51, 1767.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14702,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14703,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14704,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1760.54,,OUTPAT REV HCPCS COMBO 1, 2267.81,OTHER, 1127.76, 4012.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14705,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14706,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 624.40,,OUTPAT REV HCPCS COMBO 1, 815.01,OTHER, 444.92, 1423.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14707,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 624.40,,OUTPAT REV HCPCS COMBO 1, 815.01,OTHER, 444.92, 1423.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14708,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14709,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14710,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 500.41,,OUTPAT REV HCPCS COMBO 1, 635.79,OTHER, 283.54, 1140.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14711,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14712,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 803.60,,OUTPAT REV HCPCS COMBO 1, 984.09,OTHER, 300.36, 1831.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14713,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14714,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 831.76,,OUTPAT REV HCPCS COMBO 1, 1050.06,OTHER, 443.12, 1895.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14715,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14716,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 447.20,,OUTPAT REV HCPCS COMBO 1, 684.67,OTHER, 447.20, 1019.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14717,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14718,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2048.52,,OUTPAT REV HCPCS COMBO 1, 2685.69,OTHER, 1509.32, 4668.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14719,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14720,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2121.62,,OUTPAT REV HCPCS COMBO 1, 2768.70,OTHER, 1509.32, 4835.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14721,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 14722,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 26.05,,OUTPAT REV HCPCS COMBO 1, 34.30,OTHER, 19.78, 59.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14723,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 26.05,,OUTPAT REV HCPCS COMBO 1, 32.49,OTHER, 12.18, 59.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14724,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 267.46,,OUTPAT REV HCPCS COMBO 1, 398.65,OTHER, 267.46, 609.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14725,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 60.14,,OUTPAT REV HCPCS COMBO 1, 70.69,OTHER, 10.09, 137.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14726,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 104.38,,OUTPAT REV HCPCS COMBO 1, 122.16,OTHER, 15.20, 237.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14727,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 81.90,,OUTPAT REV HCPCS COMBO 1, 97.60,OTHER, 19.28, 186.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14728,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 81.90,,OUTPAT REV HCPCS COMBO 1, 97.60,OTHER, 19.28, 186.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14729,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 70.95,,OUTPAT REV HCPCS COMBO 1, 83.55,OTHER, 12.50, 161.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14730,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 70.95,,OUTPAT REV HCPCS COMBO 1, 83.55,OTHER, 12.50, 161.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14731,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 122.86,,OUTPAT REV HCPCS COMBO 1, 155.85,OTHER, 68.59, 280.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14732,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 67.08,,OUTPAT REV HCPCS COMBO 1, 78.98,OTHER, 11.76, 152.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14733,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 56.33,,OUTPAT REV HCPCS COMBO 1, 69.30,OTHER, 22.37, 128.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14734,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 192.21,,OUTPAT REV HCPCS COMBO 1, 229.30,OTHER, 46.28, 438.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14735,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 75.79,,OUTPAT REV HCPCS COMBO 1, 88.95,OTHER, 20.98, 172.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14736,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 72.07,,OUTPAT REV HCPCS COMBO 1, 88.95,OTHER, 20.98, 172.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14737,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 53.39,OTHER, 19.13, 98.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14738,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 53.39,OTHER, 19.13, 98.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14739,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 66.51,,OUTPAT REV HCPCS COMBO 1, 80.17,OTHER, 19.50, 151.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14740,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 41.55,,OUTPAT REV HCPCS COMBO 1, 54.61,OTHER, 31.20, 94.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14741,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 66.47,,OUTPAT REV HCPCS COMBO 1, 80.03,OTHER, 19.08, 151.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14742,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.72,,OUTPAT REV HCPCS COMBO 1, 79.17,OTHER, 19.08, 149.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14743,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 54.32,,OUTPAT REV HCPCS COMBO 1, 63.95,OTHER, 9.52, 123.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14744,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 20.21,,OUTPAT REV HCPCS COMBO 1, 28.28,OTHER, 20.21, 46.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14745,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 69.69,,OUTPAT REV HCPCS COMBO 1, 83.69,OTHER, 19.08, 158.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14746,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 42.46,,OUTPAT REV HCPCS COMBO 1, 53.47,OTHER, 22.03, 96.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14747,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 66.28,,OUTPAT REV HCPCS COMBO 1, 79.81,OTHER, 19.08, 151.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14748,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 35.17,,OUTPAT REV HCPCS COMBO 1, 44.64,OTHER, 19.78, 80.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14749,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 124.34,,OUTPAT REV HCPCS COMBO 1, 145.91,OTHER, 19.78, 283.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14750,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 52.76,,OUTPAT REV HCPCS COMBO 1, 64.76,OTHER, 20.36, 120.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14751,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 103.25,,OUTPAT REV HCPCS COMBO 1, 121.34,OTHER, 17.16, 235.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14752,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 70.55,,OUTPAT REV HCPCS COMBO 1, 84.76,OTHER, 19.50, 160.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14753,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 111.79,,OUTPAT REV HCPCS COMBO 1, 134.69,OTHER, 32.53, 254.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14754,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 74.42,,OUTPAT REV HCPCS COMBO 1, 90.91,OTHER, 26.84, 169.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14755,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 81.85,,OUTPAT REV HCPCS COMBO 1, 56.90,OTHER, 10.75, 186.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14756,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 56.90,OTHER, 10.75, 186.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14757,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 17.20,,OUTPAT REV HCPCS COMBO 1, 23.85,OTHER, 17.20, 39.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14758,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 17.20,,OUTPAT REV HCPCS COMBO 1, 23.85,OTHER, 17.20, 39.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14759,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 112.61,,OUTPAT REV HCPCS COMBO 1, 178.46,OTHER, 112.61, 289.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14760,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 126.85,,OUTPAT REV HCPCS COMBO 1, 178.46,OTHER, 112.61, 289.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14761,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 72.67,,OUTPAT REV HCPCS COMBO 1, 108.31,OTHER, 72.67, 165.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14762,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 64.50,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14763,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.68,,OUTPAT REV HCPCS COMBO 1, 48.71,OTHER, 32.68, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14764,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 120.73,,OUTPAT REV HCPCS COMBO 1, 179.95,OTHER, 120.73, 275.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14765,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 76.91,,OUTPAT REV HCPCS COMBO 1, 114.63,OTHER, 76.91, 175.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14766,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 17.56,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14767,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14768,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 17.56,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14769,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 17.56,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14770,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 60.63,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14771,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.53,,OUTPAT REV HCPCS COMBO 1, 67.87,OTHER, 45.53, 103.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14772,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 68.37,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14773,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 68.37,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14774,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 68.37,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14775,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 58.05,,OUTPAT REV HCPCS COMBO 1, 86.52,OTHER, 58.05, 132.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14776,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 120.81,OTHER, 36.98, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14777,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 120.81,OTHER, 36.98, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14778,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 29.76,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14779,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 29.76,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14780,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 29.76,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14781,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 17.75,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14782,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 17.75,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14783,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 17.75,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14784,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 5.59,,OUTPAT REV HCPCS COMBO 1, 7.12,OTHER, 3.24, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14785,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 8.07,OTHER, 3.12, 14.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14786,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 27.22,,OUTPAT REV HCPCS COMBO 1, 33.86,OTHER, 12.40, 62.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14787,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 27.22,,OUTPAT REV HCPCS COMBO 1, 33.86,OTHER, 12.40, 62.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14788,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 64.07,,OUTPAT REV HCPCS COMBO 1, 75.71,OTHER, 12.40, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14789,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 64.07,,OUTPAT REV HCPCS COMBO 1, 75.71,OTHER, 12.40, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14790,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 106.06,,OUTPAT REV HCPCS COMBO 1, 145.60,OTHER, 105.66, 241.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14791,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 106.06,,OUTPAT REV HCPCS COMBO 1, 145.60,OTHER, 105.66, 241.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14792,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 211.56,,OUTPAT REV HCPCS COMBO 1, 262.66,OTHER, 94.12, 482.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14793,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 350.08,,OUTPAT REV HCPCS COMBO 1, 428.98,OTHER, 131.99, 797.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14794,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 87.01,,OUTPAT REV HCPCS COMBO 1, 129.68,OTHER, 87.01, 198.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14795,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 164.26,,OUTPAT REV HCPCS COMBO 1, 244.83,OTHER, 164.26, 374.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14796,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 164.26,,OUTPAT REV HCPCS COMBO 1, 244.83,OTHER, 164.26, 374.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14797,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.44,,OUTPAT REV HCPCS COMBO 1, 53.15,OTHER, 6.50, 103.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14798,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 31.79,,OUTPAT REV HCPCS COMBO 1, 38.90,OTHER, 11.76, 72.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14799,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 117.64,,OUTPAT REV HCPCS COMBO 1, 146.83,OTHER, 55.61, 268.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14800,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 16.23,,OUTPAT REV HCPCS COMBO 1, 20.13,OTHER, 7.13, 37.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14801,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 16.23,,OUTPAT REV HCPCS COMBO 1, 20.13,OTHER, 7.13, 37.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14802,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 23.11,,OUTPAT REV HCPCS COMBO 1, 28.92,OTHER, 11.21, 52.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14803,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 23.11,,OUTPAT REV HCPCS COMBO 1, 28.92,OTHER, 11.21, 52.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14804,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 51.60,,OUTPAT REV HCPCS COMBO 1, 60.58,OTHER, 8.33, 117.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14805,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 51.60,,OUTPAT REV HCPCS COMBO 1, 60.58,OTHER, 8.33, 117.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14806,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 41.87,,OUTPAT REV HCPCS COMBO 1, 50.88,OTHER, 13.98, 95.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14807,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 58.52,,OUTPAT REV HCPCS COMBO 1, 71.06,OTHER, 19.36, 133.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14808,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 92.38,,OUTPAT REV HCPCS COMBO 1, 109.86,OTHER, 20.82, 210.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14809,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.53,,OUTPAT REV HCPCS COMBO 1, 80.16,OTHER, 24.14, 149.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14810,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.53,,OUTPAT REV HCPCS COMBO 1, 80.16,OTHER, 24.14, 149.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14811,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 63.10,OTHER, 20.98, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14812,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 63.10,OTHER, 20.98, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14813,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 42.77,,OUTPAT REV HCPCS COMBO 1, 50.79,OTHER, 9.34, 97.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14814,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 42.77,,OUTPAT REV HCPCS COMBO 1, 50.79,OTHER, 9.34, 97.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14815,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 79.55,,OUTPAT REV HCPCS COMBO 1, 100.38,OTHER, 42.16, 181.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14816,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 97.65,,OUTPAT REV HCPCS COMBO 1, 121.92,OTHER, 46.34, 222.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14817,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 37.84,,OUTPAT REV HCPCS COMBO 1, 50.20,OTHER, 30.37, 86.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14818,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 96.70,,OUTPAT REV HCPCS COMBO 1, 116.31,OTHER, 27.31, 220.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14819,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 40.85,,OUTPAT REV HCPCS COMBO 1, 49.78,OTHER, 14.24, 93.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14820,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 50.98,,OUTPAT REV HCPCS COMBO 1, 63.44,OTHER, 23.30, 116.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14821,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 30.50,,OUTPAT REV HCPCS COMBO 1, 36.36,OTHER, 7.22, 69.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14822,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 30.50,,OUTPAT REV HCPCS COMBO 1, 36.36,OTHER, 7.22, 69.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14823,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 27.61,,OUTPAT REV HCPCS COMBO 1, 33.07,OTHER, 7.22, 62.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14824,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 15.70,,OUTPAT REV HCPCS COMBO 1, 19.33,OTHER, 6.31, 35.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14825,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.02,,OUTPAT REV HCPCS COMBO 1, 33.34,OTHER, 6.38, 63.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14826,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 56.73,OTHER, 22.92, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14827,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 100.38,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14828,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 107.07,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14829,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 100.38,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14830,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 100.80,,OUTPAT REV HCPCS COMBO 1, 123.66,OTHER, 38.58, 229.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14831,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.45,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14832,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.45,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14833,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.45,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14834,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 56.84,,OUTPAT REV HCPCS COMBO 1, 69.24,OTHER, 19.70, 129.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14835,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 42.18,,OUTPAT REV HCPCS COMBO 1, 49.97,OTHER, 8.69, 96.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14836,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 35.26,,OUTPAT REV HCPCS COMBO 1, 44.47,OTHER, 18.58, 80.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14837,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 53.64,,OUTPAT REV HCPCS COMBO 1, 65.14,OTHER, 17.74, 122.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14838,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 71.10,,OUTPAT REV HCPCS COMBO 1, 87.25,OTHER, 27.30, 162.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14839,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 71.10,,OUTPAT REV HCPCS COMBO 1, 87.25,OTHER, 27.30, 162.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14840,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 46.87,,OUTPAT REV HCPCS COMBO 1, 59.01,OTHER, 24.29, 106.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14841,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 104.53,,OUTPAT REV HCPCS COMBO 1, 127.93,OTHER, 36.36, 240.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14842,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 105.53,,OUTPAT REV HCPCS COMBO 1, 127.93,OTHER, 36.36, 240.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14843,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.46,OTHER, 15.47, 105.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14844,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 10.32,,OUTPAT REV HCPCS COMBO 1, 13.69,OTHER, 8.28, 23.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14845,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 61.16,,OUTPAT REV HCPCS COMBO 1, 73.71,OTHER, 17.87, 139.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14846,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 72.21,,OUTPAT REV HCPCS COMBO 1, 87.73,OTHER, 24.06, 164.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14847,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 72.21,,OUTPAT REV HCPCS COMBO 1, 87.73,OTHER, 24.06, 164.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14848,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 53.47,,OUTPAT REV HCPCS COMBO 1, 66.31,OTHER, 23.47, 121.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14849,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 53.47,,OUTPAT REV HCPCS COMBO 1, 66.31,OTHER, 23.47, 121.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14850,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 160.20,,OUTPAT REV HCPCS COMBO 1, 190.19,OTHER, 34.69, 365.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14851,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 181.18,,OUTPAT REV HCPCS COMBO 1, 214.01,OTHER, 34.69, 412.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14852,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 39.85,,OUTPAT REV HCPCS COMBO 1, 47.49,OTHER, 9.37, 90.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14853,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 39.85,,OUTPAT REV HCPCS COMBO 1, 47.49,OTHER, 9.37, 90.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14854,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.68,,OUTPAT REV HCPCS COMBO 1, 41.70,OTHER, 19.28, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14855,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 49.11,,OUTPAT REV HCPCS COMBO 1, 59.73,OTHER, 16.63, 111.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14856,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 26.30,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14857,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 26.30,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14858,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 26.30,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14859,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.88,,OUTPAT REV HCPCS COMBO 1, 39.11,OTHER, 7.46, 74.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14860,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.88,,OUTPAT REV HCPCS COMBO 1, 39.11,OTHER, 7.46, 74.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14861,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 79.45,,OUTPAT REV HCPCS COMBO 1, 93.47,OTHER, 13.62, 181.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14862,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 79.45,,OUTPAT REV HCPCS COMBO 1, 93.47,OTHER, 13.62, 181.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14863,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.12,,OUTPAT REV HCPCS COMBO 1, 45.06,OTHER, 16.97, 82.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14864,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.16,,OUTPAT REV HCPCS COMBO 1, 76.21,OTHER, 9.31, 148.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14865,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 59.05,,OUTPAT REV HCPCS COMBO 1, 72.23,OTHER, 21.72, 134.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14866,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 59.05,,OUTPAT REV HCPCS COMBO 1, 72.23,OTHER, 21.72, 134.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14867,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 60.77,,OUTPAT REV HCPCS COMBO 1, 75.36,OTHER, 26.66, 138.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14868,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 60.77,,OUTPAT REV HCPCS COMBO 1, 75.36,OTHER, 26.66, 138.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14869,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 104.58,,OUTPAT REV HCPCS COMBO 1, 127.42,OTHER, 36.38, 238.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14870,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 104.58,,OUTPAT REV HCPCS COMBO 1, 127.42,OTHER, 36.38, 238.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14871,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 76.99,,OUTPAT REV HCPCS COMBO 1, 93.87,OTHER, 27.06, 175.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14872,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 110.87,,OUTPAT REV HCPCS COMBO 1, 135.49,OTHER, 40.24, 252.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14873,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 110.87,,OUTPAT REV HCPCS COMBO 1, 135.49,OTHER, 40.24, 252.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14874,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 64.07,,OUTPAT REV HCPCS COMBO 1, 83.83,OTHER, 46.51, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14875,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 57.62,,OUTPAT REV HCPCS COMBO 1, 73.72,OTHER, 34.82, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14876,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 58.91,,OUTPAT REV HCPCS COMBO 1, 75.45,OTHER, 35.93, 134.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14877,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 100.08,,OUTPAT REV HCPCS COMBO 1, 121.64,OTHER, 33.53, 228.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14878,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 59.37,,OUTPAT REV HCPCS COMBO 1, 69.17,OTHER, 7.34, 135.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14879,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 104.71,,OUTPAT REV HCPCS COMBO 1, 124.67,OTHER, 24.19, 238.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14880,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 63.21,,OUTPAT REV HCPCS COMBO 1, 76.46,OTHER, 19.63, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14881,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 58.51,,OUTPAT REV HCPCS COMBO 1, 71.48,OTHER, 21.17, 133.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14882,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 182.22,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14883,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 66.65,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14884,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.48,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14885,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.48,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14886,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.48,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14887,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 52.23,,OUTPAT REV HCPCS COMBO 1, 64.96,OTHER, 23.70, 119.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14888,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.38,,OUTPAT REV HCPCS COMBO 1, 34.98,OTHER, 11.54, 64.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14889,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 171.35,,OUTPAT REV HCPCS COMBO 1, 203.52,OTHER, 37.54, 390.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14890,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 49.02,,OUTPAT REV HCPCS COMBO 1, 61.71,OTHER, 25.39, 111.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14891,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 21.39,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14892,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 21.39,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14893,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 21.39,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14894,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 23.75,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14895,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 23.75,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14896,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 23.75,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14897,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 11.27,,OUTPAT REV HCPCS COMBO 1, 14.14,OTHER, 5.66, 25.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14898,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 55.33,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 6.84, 126.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14899,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 55.33,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 6.84, 126.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14900,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 48.07,,OUTPAT REV HCPCS COMBO 1, 57.91,OTHER, 13.97, 109.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14901,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 30.89,,OUTPAT REV HCPCS COMBO 1, 37.55,OTHER, 10.37, 70.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14902,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 77.81,,OUTPAT REV HCPCS COMBO 1, 94.73,OTHER, 26.76, 177.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14903,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 77.81,,OUTPAT REV HCPCS COMBO 1, 94.73,OTHER, 26.76, 177.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14904,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 77.64,,OUTPAT REV HCPCS COMBO 1, 94.52,OTHER, 26.66, 176.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14905,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 77.64,,OUTPAT REV HCPCS COMBO 1, 94.52,OTHER, 26.66, 176.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14906,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 55.24,,OUTPAT REV HCPCS COMBO 1, 67.05,OTHER, 18.12, 125.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14907,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 59.34,,OUTPAT REV HCPCS COMBO 1, 74.92,OTHER, 31.62, 135.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14908,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 39.60,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14909,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 39.60,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14910,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 39.60,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14911,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 82.50,,OUTPAT REV HCPCS COMBO 1, 99.83,OTHER, 25.80, 188.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14912,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 129.43,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14913,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14914,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14915,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14916,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14917,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14918,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 127.54,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14919,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 77.00,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14920,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 118.72,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14921,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 18.49,,OUTPAT REV HCPCS COMBO 1, 25.93,OTHER, 18.49, 42.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14922,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 57.34,,OUTPAT REV HCPCS COMBO 1, 69.04,OTHER, 16.46, 130.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14923,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.69,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14924,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.69,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14925,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.69,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14926,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14927,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14928,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14929,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14930,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 58.18,,OUTPAT REV HCPCS COMBO 1, 70.04,OTHER, 16.66, 132.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14931,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 37.18,,OUTPAT REV HCPCS COMBO 1, 51.00,OTHER, 8.70, 111.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14932,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 48.99,,OUTPAT REV HCPCS COMBO 1, 51.00,OTHER, 8.70, 111.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14933,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 71.38,,OUTPAT REV HCPCS COMBO 1, 85.45,OTHER, 18.42, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14934,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.77,OTHER, 28.37, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14935,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 44.57,,OUTPAT REV HCPCS COMBO 1, 54.77,OTHER, 17.44, 101.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14936,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 44.57,,OUTPAT REV HCPCS COMBO 1, 54.77,OTHER, 17.44, 101.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14937,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 60.48,OTHER, 9.92, 116.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14938,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 60.48,OTHER, 9.92, 116.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14939,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 117.27,,OUTPAT REV HCPCS COMBO 1, 149.05,OTHER, 66.68, 267.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14940,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 27.95,,OUTPAT REV HCPCS COMBO 1, 43.46,OTHER, 27.95, 63.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14941,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 34.70,,OUTPAT REV HCPCS COMBO 1, 43.01,OTHER, 15.12, 79.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14942,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 34.70,,OUTPAT REV HCPCS COMBO 1, 43.01,OTHER, 15.12, 79.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14943,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 33.76,,OUTPAT REV HCPCS COMBO 1, 40.64,OTHER, 9.65, 76.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14944,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 172.39,,OUTPAT REV HCPCS COMBO 1, 204.04,OTHER, 34.72, 392.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14945,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.72,,OUTPAT REV HCPCS COMBO 1, 57.49,OTHER, 23.41, 104.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14946,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 135.39,,OUTPAT REV HCPCS COMBO 1, 159.56,OTHER, 24.40, 308.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14947,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 135.39,,OUTPAT REV HCPCS COMBO 1, 159.56,OTHER, 24.40, 308.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14948,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 71.67,,OUTPAT REV HCPCS COMBO 1, 74.79,OTHER, 18.60, 163.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14949,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 52.25,,OUTPAT REV HCPCS COMBO 1, 74.79,OTHER, 18.60, 163.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14950,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 94.17,,OUTPAT REV HCPCS COMBO 1, 120.40,OTHER, 56.53, 214.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14951,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 94.17,,OUTPAT REV HCPCS COMBO 1, 120.40,OTHER, 56.53, 214.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14952,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 91.30,,OUTPAT REV HCPCS COMBO 1, 110.95,OTHER, 30.54, 208.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14953,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.70,,OUTPAT REV HCPCS COMBO 1, 54.17,OTHER, 9.52, 104.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14954,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 37.08,,OUTPAT REV HCPCS COMBO 1, 44.45,OTHER, 9.82, 84.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14955,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 37.08,,OUTPAT REV HCPCS COMBO 1, 44.45,OTHER, 9.82, 84.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14956,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 71.50,,OUTPAT REV HCPCS COMBO 1, 86.15,OTHER, 20.81, 162.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14957,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 116.98,,OUTPAT REV HCPCS COMBO 1, 147.00,OTHER, 59.45, 266.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14958,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 116.98,,OUTPAT REV HCPCS COMBO 1, 147.00,OTHER, 59.45, 266.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14959,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.68,,OUTPAT REV HCPCS COMBO 1, 43.75,OTHER, 27.89, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14960,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 158.40,,OUTPAT REV HCPCS COMBO 1, 186.61,OTHER, 28.27, 361.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14961,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 45.87,OTHER, 7.46, 92.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14962,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 40.68,,OUTPAT REV HCPCS COMBO 1, 45.87,OTHER, 7.46, 92.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14963,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 29.56,,OUTPAT REV HCPCS COMBO 1, 35.19,OTHER, 6.83, 67.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14964,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 29.56,,OUTPAT REV HCPCS COMBO 1, 35.19,OTHER, 6.83, 67.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14965,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 23.99,,OUTPAT REV HCPCS COMBO 1, 28.87,OTHER, 6.85, 54.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14966,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 13.83,OTHER, 6.82, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14967,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 35.72,,OUTPAT REV HCPCS COMBO 1, 45.56,OTHER, 21.01, 81.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14968,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 75.35,,OUTPAT REV HCPCS COMBO 1, 92.72,OTHER, 30.04, 171.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14969,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 75.35,,OUTPAT REV HCPCS COMBO 1, 92.72,OTHER, 30.04, 171.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14970,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 82.30,,OUTPAT REV HCPCS COMBO 1, 102.79,OTHER, 39.19, 187.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14971,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 79.71,,OUTPAT REV HCPCS COMBO 1, 97.17,OTHER, 27.91, 181.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14972,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 71.08,,OUTPAT REV HCPCS COMBO 1, 90.21,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14973,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 76.69,,OUTPAT REV HCPCS COMBO 1, 90.21,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14974,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 76.69,,OUTPAT REV HCPCS COMBO 1, 93.39,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14975,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 20.61,,OUTPAT REV HCPCS COMBO 1, 24.66,OTHER, 5.28, 46.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14976,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 20.61,,OUTPAT REV HCPCS COMBO 1, 24.66,OTHER, 5.28, 46.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14977,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14978,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14979,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14980,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 35.17,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14981,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 35.17,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14982,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.73,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14983,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 171.18,,OUTPAT REV HCPCS COMBO 1, 144.06,OTHER, 15.47, 390.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14984,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 76.05,,OUTPAT REV HCPCS COMBO 1, 144.06,OTHER, 15.47, 390.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14985,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.58,,OUTPAT REV HCPCS COMBO 1, 141.59,OTHER, 25.68, 394.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14986,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 173.02,,OUTPAT REV HCPCS COMBO 1, 141.59,OTHER, 25.68, 394.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14987,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 112.01,,OUTPAT REV HCPCS COMBO 1, 136.35,OTHER, 38.44, 255.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14988,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 82.46,,OUTPAT REV HCPCS COMBO 1, 103.27,OTHER, 40.46, 187.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14989,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 61.06,,OUTPAT REV HCPCS COMBO 1, 76.88,OTHER, 31.67, 139.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14990,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 151.36,,OUTPAT REV HCPCS COMBO 1, 178.83,OTHER, 29.15, 344.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14991,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 71.31,,OUTPAT REV HCPCS COMBO 1, 88.43,OTHER, 31.30, 162.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14992,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 24.98,,OUTPAT REV HCPCS COMBO 1, 30.02,OTHER, 6.92, 56.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14993,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 24.98,,OUTPAT REV HCPCS COMBO 1, 30.02,OTHER, 6.92, 56.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14994,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 38.86,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14995,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 38.86,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14996,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 7.98,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14997,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 152.72,,OUTPAT REV HCPCS COMBO 1, 180.72,OTHER, 30.61, 348.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14998,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 264.33,,OUTPAT REV HCPCS COMBO 1, 302.95,OTHER, 11.66, 602.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 14999,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 64.43,,OUTPAT REV HCPCS COMBO 1, 81.90,OTHER, 36.67, 146.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15000,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15001,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15002,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15003,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15004,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 70.02,,OUTPAT REV HCPCS COMBO 1, 86.80,OTHER, 30.58, 159.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15005,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 70.02,,OUTPAT REV HCPCS COMBO 1, 86.80,OTHER, 30.58, 159.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15006,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 89.69,,OUTPAT REV HCPCS COMBO 1, 107.35,OTHER, 23.12, 204.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15007,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 89.69,,OUTPAT REV HCPCS COMBO 1, 107.35,OTHER, 23.12, 204.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15008,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 44.84,,OUTPAT REV HCPCS COMBO 1, 53.27,OTHER, 9.89, 102.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15009,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 44.84,,OUTPAT REV HCPCS COMBO 1, 53.27,OTHER, 9.89, 102.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15010,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 64.16,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15011,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 64.16,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15012,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 64.16,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15013,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 41.28,,OUTPAT REV HCPCS COMBO 1, 51.95,OTHER, 21.29, 94.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15014,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 59.68,,OUTPAT REV HCPCS COMBO 1, 73.53,OTHER, 24.19, 136.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15015,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 120.40,,OUTPAT REV HCPCS COMBO 1, 154.17,OTHER, 73.24, 274.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15016,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 120.40,,OUTPAT REV HCPCS COMBO 1, 154.17,OTHER, 73.24, 274.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15017,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 39.56,,OUTPAT REV HCPCS COMBO 1, 49.79,OTHER, 20.42, 90.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15018,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.18,,OUTPAT REV HCPCS COMBO 1, 38.32,OTHER, 7.46, 73.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15019,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 30.09,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, 7.63, 68.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15020,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 47.67,,OUTPAT REV HCPCS COMBO 1, 58.51,OTHER, 18.37, 108.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15021,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.73,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 8.27, 74.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15022,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.64,,OUTPAT REV HCPCS COMBO 1, 79.41,OTHER, 20.42, 149.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15023,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.64,,OUTPAT REV HCPCS COMBO 1, 79.41,OTHER, 20.42, 149.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15024,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 64.36,,OUTPAT REV HCPCS COMBO 1, 78.90,OTHER, 24.40, 146.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15025,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 64.36,,OUTPAT REV HCPCS COMBO 1, 78.90,OTHER, 24.40, 146.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15026,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 106.98,,OUTPAT REV HCPCS COMBO 1, 126.89,OTHER, 22.69, 243.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15027,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 69.32,,OUTPAT REV HCPCS COMBO 1, 82.99,OTHER, 17.95, 157.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15028,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 69.32,,OUTPAT REV HCPCS COMBO 1, 82.99,OTHER, 17.95, 157.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15029,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 33.26,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15030,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 33.26,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15031,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 33.26,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15032,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 18.22,,OUTPAT REV HCPCS COMBO 1, 22.60,OTHER, 8.00, 41.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15033,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 18.22,,OUTPAT REV HCPCS COMBO 1, 22.60,OTHER, 8.00, 41.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15034,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 26.70,,OUTPAT REV HCPCS COMBO 1, 31.87,OTHER, 6.50, 60.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15035,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.90,,OUTPAT REV HCPCS COMBO 1, 39.10,OTHER, 7.32, 74.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15036,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 63.71,,OUTPAT REV HCPCS COMBO 1, 76.33,OTHER, 16.72, 145.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15037,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 87.18,,OUTPAT REV HCPCS COMBO 1, 103.71,OTHER, 19.75, 198.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15038,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15039,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15040,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15041,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 69.10,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 29.96, 157.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15042,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 80.90,,OUTPAT REV HCPCS COMBO 1, 97.04,OTHER, 21.67, 184.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15043,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.30,,OUTPAT REV HCPCS COMBO 1, 42.88,OTHER, 6.94, 82.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15044,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 37.42,,OUTPAT REV HCPCS COMBO 1, 43.80,OTHER, 5.47, 85.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15045,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 15.00,,OUTPAT REV HCPCS COMBO 1, 17.85,OTHER, 3.41, 34.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15046,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 15.00,,OUTPAT REV HCPCS COMBO 1, 17.85,OTHER, 3.41, 34.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15047,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 18.18,,OUTPAT REV HCPCS COMBO 1, 21.46,OTHER, 3.41, 41.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15048,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 18.18,,OUTPAT REV HCPCS COMBO 1, 21.46,OTHER, 3.41, 41.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15049,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 22.31,OTHER, .01, 84.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15050,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.94,,OUTPAT REV HCPCS COMBO 1, 22.31,OTHER, .01, 84.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15051,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 37.42,,OUTPAT REV HCPCS COMBO 1, 44.71,OTHER, 9.31, 85.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15052,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 31.95,,OUTPAT REV HCPCS COMBO 1, 37.65,OTHER, 5.75, 72.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15053,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 31.95,,OUTPAT REV HCPCS COMBO 1, 37.65,OTHER, 5.75, 72.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15054,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 16.77,,OUTPAT REV HCPCS COMBO 1, 19.92,OTHER, 3.66, 38.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15055,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 27.38,,OUTPAT REV HCPCS COMBO 1, 32.63,OTHER, 6.46, 62.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15056,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 79.81,,OUTPAT REV HCPCS COMBO 1, 96.77,OTHER, 25.78, 181.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15057,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 106.94,,OUTPAT REV HCPCS COMBO 1, 129.31,OTHER, 33.04, 243.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15058,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 111.37,,OUTPAT REV HCPCS COMBO 1, 130.54,OTHER, 17.06, 253.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15059,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 82.42,,OUTPAT REV HCPCS COMBO 1, 98.34,OTHER, 19.93, 187.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15060,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 73.75,,OUTPAT REV HCPCS COMBO 1, 89.00,OTHER, 22.06, 168.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15061,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 83.42,,OUTPAT REV HCPCS COMBO 1, 98.22,OTHER, 14.66, 190.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15062,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.18,,OUTPAT REV HCPCS COMBO 1, 54.63,OTHER, 13.99, 102.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15063,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 56.33,,OUTPAT REV HCPCS COMBO 1, 70.40,OTHER, 27.00, 128.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15064,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 25.05,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15065,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 24.89,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15066,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 25.05,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15067,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15068,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15069,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15070,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15071,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 35.35,,OUTPAT REV HCPCS COMBO 1, 41.60,OTHER, 6.14, 80.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15072,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 22.36,,OUTPAT REV HCPCS COMBO 1, 26.32,OTHER, 3.89, 50.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15073,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 30.35,,OUTPAT REV HCPCS COMBO 1, 36.35,OTHER, 7.93, 69.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15074,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 73.10,,OUTPAT REV HCPCS COMBO 1, 61.85,OTHER, 8.65, 166.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15075,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.20,,OUTPAT REV HCPCS COMBO 1, 61.85,OTHER, 8.65, 166.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15076,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.15,,OUTPAT REV HCPCS COMBO 1, 76.67,OTHER, 11.26, 148.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15077,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 510.99,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15078,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 138.89,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15079,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15080,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15081,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15082,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15083,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15084,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15085,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15086,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15087,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15088,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15089,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15090,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15091,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15092,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15093,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15094,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15095,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15096,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15097,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15098,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15099,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15100,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15101,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15102,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15103,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15104,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15105,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15106,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15107,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15108,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15109,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15110,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15111,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15112,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15113,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15114,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15115,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 26.51,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15116,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15117,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15118,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15119,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15120,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 13.80,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15121,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15122,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15123,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15124,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15125,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15126,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15127,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15128,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15129,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15130,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15131,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15132,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15133,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15134,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15135,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15136,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15137,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15138,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15139,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 161.14,,OUTPAT REV HCPCS COMBO 1, 189.29,OTHER, 26.45, 367.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15140,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 98.39,,OUTPAT REV HCPCS COMBO 1, 115.17,OTHER, 14.46, 224.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15141,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 57.32,,OUTPAT REV HCPCS COMBO 1, 91.70,OTHER, 17.41, 220.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15142,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 96.87,,OUTPAT REV HCPCS COMBO 1, 91.70,OTHER, 17.41, 220.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15143,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 39.70,,OUTPAT REV HCPCS COMBO 1, 48.91,OTHER, 16.07, 90.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15144,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 37.63,,OUTPAT REV HCPCS COMBO 1, 45.23,OTHER, 10.51, 85.75,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15145,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 13.48,,OUTPAT REV HCPCS COMBO 1, 17.08,OTHER, 7.46, 30.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15146,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 13.48,,OUTPAT REV HCPCS COMBO 1, 17.08,OTHER, 7.46, 30.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15147,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 48.27,,OUTPAT REV HCPCS COMBO 1, 59.25,OTHER, 18.65, 110.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15148,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 75.07,,OUTPAT REV HCPCS COMBO 1, 93.98,OTHER, 36.65, 171.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15149,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 113.28,,OUTPAT REV HCPCS COMBO 1, 137.37,OTHER, 36.65, 258.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15150,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 64.24,,OUTPAT REV HCPCS COMBO 1, 78.46,OTHER, 23.14, 146.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15151,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 56.01,,OUTPAT REV HCPCS COMBO 1, 67.64,OTHER, 17.28, 127.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15152,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 55.87,,OUTPAT REV HCPCS COMBO 1, 67.64,OTHER, 17.28, 127.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15153,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 62.28,,OUTPAT REV HCPCS COMBO 1, 77.69,OTHER, 29.26, 141.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15154,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 51.73,,OUTPAT REV HCPCS COMBO 1, 63.19,OTHER, 18.65, 117.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15155,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 51.66,,OUTPAT REV HCPCS COMBO 1, 65.88,OTHER, 19.79, 127.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15156,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 56.08,,OUTPAT REV HCPCS COMBO 1, 65.88,OTHER, 19.79, 127.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15157,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15158,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15159,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15160,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15161,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 60.90,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15162,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15163,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 51.97,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15164,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 48.44,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15165,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 68.37,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15166,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 104.56,,OUTPAT REV HCPCS COMBO 1, 120.82,OTHER, 17.35, 238.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15167,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 100.94,,OUTPAT REV HCPCS COMBO 1, 120.82,OTHER, 17.35, 238.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15168,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 15.65,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15169,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 64.09,,OUTPAT REV HCPCS COMBO 1, 80.94,OTHER, 29.96, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15170,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.89,,OUTPAT REV HCPCS COMBO 1, 80.94,OTHER, 29.96, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15171,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 68.68,,OUTPAT REV HCPCS COMBO 1, 85.12,OTHER, 29.96, 156.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15172,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 84.81,,OUTPAT REV HCPCS COMBO 1, 103.45,OTHER, 29.96, 193.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15173,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 58.18,,OUTPAT REV HCPCS COMBO 1, 125.05,OTHER, 24.97, 345.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15174,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 151.58,,OUTPAT REV HCPCS COMBO 1, 125.05,OTHER, 24.97, 345.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15175,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 42.94,,OUTPAT REV HCPCS COMBO 1, 50.54,OTHER, 7.46, 97.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15176,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 71.51,,OUTPAT REV HCPCS COMBO 1, 88.87,OTHER, 32.17, 162.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15177,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 52.03,,OUTPAT REV HCPCS COMBO 1, 66.43,OTHER, 30.83, 118.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15178,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 46.01,,OUTPAT REV HCPCS COMBO 1, 57.43,OTHER, 21.72, 104.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15179,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 226.29,,OUTPAT REV HCPCS COMBO 1, 265.06,OTHER, 33.95, 515.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15180,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 63.21,,OUTPAT REV HCPCS COMBO 1, 80.97,OTHER, 38.57, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15181,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 63.21,,OUTPAT REV HCPCS COMBO 1, 80.97,OTHER, 38.57, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15182,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 87.08,,OUTPAT REV HCPCS COMBO 1, 111.82,OTHER, 54.34, 198.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15183,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 141.00,,OUTPAT REV HCPCS COMBO 1, 176.22,OTHER, 67.64, 321.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15184,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 69.45,,OUTPAT REV HCPCS COMBO 1, 88.05,OTHER, 38.57, 158.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15185,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 69.45,,OUTPAT REV HCPCS COMBO 1, 88.05,OTHER, 38.57, 158.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15186,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 57.62,,OUTPAT REV HCPCS COMBO 1, 68.73,OTHER, 13.84, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15187,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 70.14,,OUTPAT REV HCPCS COMBO 1, 96.09,OTHER, 20.95, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15188,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 90.30,,OUTPAT REV HCPCS COMBO 1, 96.09,OTHER, 20.95, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15189,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 57.62,,OUTPAT REV HCPCS COMBO 1, 70.10,OTHER, 19.60, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15190,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 39.55,,OUTPAT REV HCPCS COMBO 1, 46.86,OTHER, 8.16, 90.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15191,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 39.55,,OUTPAT REV HCPCS COMBO 1, 46.86,OTHER, 8.16, 90.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15192,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 150.07,,OUTPAT REV HCPCS COMBO 1, 191.67,OTHER, 89.24, 342.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15193,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 8.04,,OUTPAT REV HCPCS COMBO 1, 12.31,OTHER, 8.04, 18.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15194,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 15.01,,OUTPAT REV HCPCS COMBO 1, 18.56,OTHER, 6.34, 34.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15195,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 27.34,,OUTPAT REV HCPCS COMBO 1, 36.21,OTHER, 21.67, 62.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15196,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.58,,OUTPAT REV HCPCS COMBO 1, 55.25,OTHER, 14.66, 103.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15197,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 31.44,,OUTPAT REV HCPCS COMBO 1, 40.13,OTHER, 18.58, 71.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15198,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 66.54,OTHER, 19.00, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15199,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 72.68,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15200,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 72.68,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15201,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 72.68,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15202,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 19.93,,OUTPAT REV HCPCS COMBO 1, 26.75,OTHER, 17.29, 45.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15203,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 41.68,,OUTPAT REV HCPCS COMBO 1, 91.08,OTHER, 16.51, 254.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15204,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 111.80,,OUTPAT REV HCPCS COMBO 1, 91.08,OTHER, 16.51, 254.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15205,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 40.42,,OUTPAT REV HCPCS COMBO 1, 50.83,OTHER, 20.72, 92.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15206,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 46.87,,OUTPAT REV HCPCS COMBO 1, 59.00,OTHER, 24.26, 106.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15207,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 52.14,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 22.02, 118.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15208,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 46.92,,OUTPAT REV HCPCS COMBO 1, 59.50,OTHER, 26.12, 106.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15209,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 46.92,,OUTPAT REV HCPCS COMBO 1, 59.50,OTHER, 26.12, 106.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15210,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 78.68,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15211,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 47.36,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15212,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 47.36,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15213,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 52.89,,OUTPAT REV HCPCS COMBO 1, 66.70,OTHER, 27.86, 120.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15214,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 52.89,,OUTPAT REV HCPCS COMBO 1, 66.70,OTHER, 27.86, 120.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15215,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 33.97,,OUTPAT REV HCPCS COMBO 1, 43.51,OTHER, 20.72, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15216,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 38.00,,OUTPAT REV HCPCS COMBO 1, 47.68,OTHER, 19.00, 86.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15217,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.58,,OUTPAT REV HCPCS COMBO 1, 58.39,OTHER, 27.86, 103.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15218,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 64.05,,OUTPAT REV HCPCS COMBO 1, 77.47,OTHER, 19.86, 145.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15219,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 50.90,,OUTPAT REV HCPCS COMBO 1, 62.50,OTHER, 19.74, 116.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15220,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 37.53,,OUTPAT REV HCPCS COMBO 1, 46.75,OTHER, 17.35, 85.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15221,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.68,,OUTPAT REV HCPCS COMBO 1, 41.14,OTHER, 16.94, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15222,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 55.83,,OUTPAT REV HCPCS COMBO 1, 67.08,OTHER, 15.47, 127.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15223,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 40.75,,OUTPAT REV HCPCS COMBO 1, 50.52,OTHER, 17.84, 92.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15224,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 21.41,,OUTPAT REV HCPCS COMBO 1, 28.18,OTHER, 16.21, 48.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15225,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 42.33,,OUTPAT REV HCPCS COMBO 1, 52.54,OTHER, 18.79, 96.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15226,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 42.33,,OUTPAT REV HCPCS COMBO 1, 52.54,OTHER, 18.79, 96.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15227,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 41.16,OTHER, 19.07, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15228,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.26,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15229,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.26,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15230,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.26,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15231,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 37.52,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15232,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 38.81,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15233,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 38.81,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15234,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 39.49,,OUTPAT REV HCPCS COMBO 1, 49.38,OTHER, 19.07, 89.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15235,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 66.65,,OUTPAT REV HCPCS COMBO 1, 80.11,OTHER, 18.55, 151.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15236,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 66.65,,OUTPAT REV HCPCS COMBO 1, 80.11,OTHER, 18.55, 151.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15237,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 314.67,,OUTPAT REV HCPCS COMBO 1, 361.76,OTHER, 18.55, 717.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15238,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 138.03,,OUTPAT REV HCPCS COMBO 1, 161.64,OTHER, 20.54, 314.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15239,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 120.30,,OUTPAT REV HCPCS COMBO 1, 158.63,OTHER, 92.44, 274.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15240,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 120.30,,OUTPAT REV HCPCS COMBO 1, 158.63,OTHER, 92.44, 274.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15241,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.75,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15242,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.75,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15243,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.75,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15244,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 102.77,,OUTPAT REV HCPCS COMBO 1, 152.44,OTHER, 102.77, 234.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15245,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15246,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15247,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15248,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15249,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15250,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15251,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15252,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15253,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 127.76,,OUTPAT REV HCPCS COMBO 1, 146.86,OTHER, 7.46, 291.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15254,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 47.30,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15255,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 47.30,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15256,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 47.30,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15257,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 39.16,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15258,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 37.22,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15259,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 39.16,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15260,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15261,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15262,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 168.35,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15263,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 59.99,,OUTPAT REV HCPCS COMBO 1, 70.78,OTHER, 11.16, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15264,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 59.99,,OUTPAT REV HCPCS COMBO 1, 70.78,OTHER, 11.16, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15265,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15266,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15267,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15268,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15269,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15270,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15271,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 59.99,,OUTPAT REV HCPCS COMBO 1, 76.50,OTHER, 35.20, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15272,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 112.23,,OUTPAT REV HCPCS COMBO 1, 149.18,OTHER, 91.25, 255.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15273,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 68.57,,OUTPAT REV HCPCS COMBO 1, 81.41,OTHER, 14.86, 156.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15274,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 68.57,,OUTPAT REV HCPCS COMBO 1, 81.41,OTHER, 14.86, 156.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15275,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 24.24,,OUTPAT REV HCPCS COMBO 1, 30.76,OTHER, 13.60, 55.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15276,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 61.36,,OUTPAT REV HCPCS COMBO 1, 72.64,OTHER, 12.41, 139.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15277,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 61.36,,OUTPAT REV HCPCS COMBO 1, 72.64,OTHER, 12.41, 139.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15278,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 66.06,,OUTPAT REV HCPCS COMBO 1, 78.26,OTHER, 13.63, 150.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15279,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 66.06,,OUTPAT REV HCPCS COMBO 1, 78.26,OTHER, 13.63, 150.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15280,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 67.12,,OUTPAT REV HCPCS COMBO 1, 78.99,OTHER, 11.64, 152.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15281,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 38.75,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15282,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 38.75,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15283,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 38.75,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15284,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 34.07,,OUTPAT REV HCPCS COMBO 1, 40.96,OTHER, 9.55, 77.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15285,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.91,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15286,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.91,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15287,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.91,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15288,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 70.00,,OUTPAT REV HCPCS COMBO 1, 82.26,OTHER, 11.65, 159.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15289,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 70.00,,OUTPAT REV HCPCS COMBO 1, 82.26,OTHER, 11.65, 159.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15290,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 63.28,,OUTPAT REV HCPCS COMBO 1, 74.74,OTHER, 12.11, 144.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15291,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 76.88,,OUTPAT REV HCPCS COMBO 1, 91.00,OTHER, 15.55, 175.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15292,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 57.47,,OUTPAT REV HCPCS COMBO 1, 68.31,OTHER, 12.82, 130.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15293,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 14.19,,OUTPAT REV HCPCS COMBO 1, 17.74,OTHER, 6.84, 32.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15294,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 17.99,,OUTPAT REV HCPCS COMBO 1, 22.99,OTHER, 10.78, 40.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15295,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 24.94,,OUTPAT REV HCPCS COMBO 1, 29.95,OTHER, 6.84, 56.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15296,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 34.74,,OUTPAT REV HCPCS COMBO 1, 42.41,OTHER, 12.46, 79.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15297,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 24.33,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15298,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 22.66,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15299,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 22.66,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15300,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 22.74,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15301,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 22.74,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15302,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 31.96,,OUTPAT REV HCPCS COMBO 1, 38.14,OTHER, 7.76, 72.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15303,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 31.96,,OUTPAT REV HCPCS COMBO 1, 38.14,OTHER, 7.76, 72.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15304,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 23.16,,OUTPAT REV HCPCS COMBO 1, 28.29,OTHER, 8.38, 52.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15305,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.72,OTHER, 28.16, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15306,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 260.02,,OUTPAT REV HCPCS COMBO 1, 299.39,OTHER, 17.26, 592.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15307,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.69,,OUTPAT REV HCPCS COMBO 1, 40.67,OTHER, 14.88, 74.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15308,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 34.45,,OUTPAT REV HCPCS COMBO 1, 43.08,OTHER, 16.61, 78.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15309,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 102.77,,OUTPAT REV HCPCS COMBO 1, 121.25,OTHER, 19.08, 234.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15310,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.89,OTHER, 28.87, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15311,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15312,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15313,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15314,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15315,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15316,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 162.17,,OUTPAT REV HCPCS COMBO 1, 198.86,OTHER, 61.69, 369.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15317,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 162.17,,OUTPAT REV HCPCS COMBO 1, 198.86,OTHER, 61.69, 369.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15318,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 67.57,,OUTPAT REV HCPCS COMBO 1, 100.71,OTHER, 67.57, 153.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15319,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 182.09,,OUTPAT REV HCPCS COMBO 1, 221.47,OTHER, 61.69, 415.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15320,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 56.71,,OUTPAT REV HCPCS COMBO 1, 76.43,OTHER, 50.53, 129.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15321,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 207.69,,OUTPAT REV HCPCS COMBO 1, 265.03,OTHER, 122.54, 473.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15322,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15323,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 64.50,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15324,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 64.50,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15325,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 266.63,,OUTPAT REV HCPCS COMBO 1, 445.68,OTHER, 266.63, 607.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15326,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15327,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15328,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15329,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 160.23,,OUTPAT REV HCPCS COMBO 1, 193.99,OTHER, 50.53, 365.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15330,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 160.23,,OUTPAT REV HCPCS COMBO 1, 193.99,OTHER, 50.53, 365.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15331,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15332,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 142.33,,OUTPAT REV HCPCS COMBO 1, 173.66,OTHER, 50.53, 324.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15333,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.89,OTHER, 28.87, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15334,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 75.34,,OUTPAT REV HCPCS COMBO 1, 204.22,OTHER, 50.53, 599.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15335,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 263.13,,OUTPAT REV HCPCS COMBO 1, 204.22,OTHER, 50.53, 599.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15336,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 116.09,,OUTPAT REV HCPCS COMBO 1, 146.52,OTHER, 61.69, 264.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15337,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 116.09,,OUTPAT REV HCPCS COMBO 1, 146.52,OTHER, 61.69, 264.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15338,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 62.25,OTHER, 23.83, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15339,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 62.25,OTHER, 23.83, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15340,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 33.97,,OUTPAT REV HCPCS COMBO 1, 43.07,OTHER, 18.86, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15341,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 33.97,,OUTPAT REV HCPCS COMBO 1, 43.07,OTHER, 18.86, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15342,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 33.97,,OUTPAT REV HCPCS COMBO 1, 44.25,OTHER, 23.81, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15343,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 17.88,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15344,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 83.33,,OUTPAT REV HCPCS COMBO 1, 100.14,OTHER, 23.14, 189.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15345,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 627.37,,OUTPAT REV HCPCS COMBO 1, 800.72,OTHER, 370.73, 1429.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15346,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 627.37,,OUTPAT REV HCPCS COMBO 1, 800.72,OTHER, 370.73, 1429.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15347,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 59.91,OTHER, 38.32, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15348,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 59.91,OTHER, 38.32, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15349,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 238.65,,OUTPAT REV HCPCS COMBO 1, 294.34,OTHER, 97.97, 543.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15350,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15351,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15352,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 13.33,,OUTPAT REV HCPCS COMBO 1, 16.75,OTHER, 6.79, 30.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15353,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 13.33,,OUTPAT REV HCPCS COMBO 1, 16.75,OTHER, 6.79, 30.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15354,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 48.34,,OUTPAT REV HCPCS COMBO 1, 56.81,OTHER, 8.06, 110.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15355,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.99,,OUTPAT REV HCPCS COMBO 1, 39.98,OTHER, 10.56, 75.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15356,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 33.11,,OUTPAT REV HCPCS COMBO 1, 41.73,OTHER, 17.35, 75.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15357,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2550.94,,OUTPAT REV HCPCS COMBO 1, 3802.17,OTHER, 2550.94, 5813.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15358,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 48.44,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15359,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 48.44,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15360,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 12.69,,OUTPAT REV HCPCS COMBO 1, 23.30,OTHER, 12.69, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15361,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 25.59,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15362,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 12.79,,OUTPAT REV HCPCS COMBO 1, 23.42,OTHER, 12.79, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15363,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 55.47,,OUTPAT REV HCPCS COMBO 1, 82.68,OTHER, 55.47, 126.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15364,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15365,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.79,,OUTPAT REV HCPCS COMBO 1, 149.84,OTHER, 65.79, 315.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15366,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.79,,OUTPAT REV HCPCS COMBO 1, 149.84,OTHER, 65.79, 315.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15367,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 59.75,,OUTPAT REV HCPCS COMBO 1, 89.06,OTHER, 59.75, 136.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15368,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 21.50,,OUTPAT REV HCPCS COMBO 1, 41.40,OTHER, 21.50, 71.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15369,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 21.50,,OUTPAT REV HCPCS COMBO 1, 41.40,OTHER, 21.50, 71.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15370,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 255.16,,OUTPAT REV HCPCS COMBO 1, 356.50,OTHER, 255.16, 581.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15371,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 533.11,,OUTPAT REV HCPCS COMBO 1, 687.64,OTHER, 345.38, 1214.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15372,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 135.24,,OUTPAT REV HCPCS COMBO 1, 201.57,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15373,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15374,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15375,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.55,,OUTPAT REV HCPCS COMBO 1, 60.00,OTHER, 36.55, 83.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15376,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 22.12,,OUTPAT REV HCPCS COMBO 1, 36.74,OTHER, 22.12, 50.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15377,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 22.12,,OUTPAT REV HCPCS COMBO 1, 36.74,OTHER, 22.12, 50.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15378,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15379,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15380,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15381,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15382,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15383,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15384,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15385,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 34.29,,OUTPAT REV HCPCS COMBO 1, 51.11,OTHER, 34.29, 78.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15386,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 58.79,,OUTPAT REV HCPCS COMBO 1, 87.62,OTHER, 58.79, 133.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15387,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 58.79,,OUTPAT REV HCPCS COMBO 1, 87.62,OTHER, 58.79, 133.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15388,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15389,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 67.85,,OUTPAT REV HCPCS COMBO 1, 111.30,OTHER, 67.85, 154.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15390,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 67.85,,OUTPAT REV HCPCS COMBO 1, 111.30,OTHER, 67.85, 154.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15391,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15392,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15393,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 73.49,,OUTPAT REV HCPCS COMBO 1, 104.75,OTHER, 73.49, 167.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15394,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 73.49,,OUTPAT REV HCPCS COMBO 1, 104.75,OTHER, 73.49, 167.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15395,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 4.30,,OUTPAT REV HCPCS COMBO 1, 12.78,OTHER, 4.30, 33.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15396,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 14.22,,OUTPAT REV HCPCS COMBO 1, 17.36,OTHER, 5.09, 32.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15397,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 130.68,,OUTPAT REV HCPCS COMBO 1, 184.48,OTHER, 130.68, 297.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15398,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 146.42,,OUTPAT REV HCPCS COMBO 1, 202.35,OTHER, 146.42, 333.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15399,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 63.61,,OUTPAT REV HCPCS COMBO 1, 99.37,OTHER, 63.61, 144.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15400,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.39,,OUTPAT REV HCPCS COMBO 1, 88.44,OTHER, 59.56, 149.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15401,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 84.22,,OUTPAT REV HCPCS COMBO 1, 131.72,OTHER, 84.22, 191.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15402,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 82.81,,OUTPAT REV HCPCS COMBO 1, 117.05,OTHER, 82.81, 188.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15403,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 126.51,,OUTPAT REV HCPCS COMBO 1, 179.75,OTHER, 126.51, 288.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15404,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 109.46,,OUTPAT REV HCPCS COMBO 1, 158.52,OTHER, 109.46, 249.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15405,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 132.20,,OUTPAT REV HCPCS COMBO 1, 186.21,OTHER, 132.20, 301.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15406,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 63.26,,OUTPAT REV HCPCS COMBO 1, 83.96,OTHER, 50.93, 144.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15407,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 102.00,,OUTPAT REV HCPCS COMBO 1, 167.44,OTHER, 102.00, 232.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15408,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 106.26,,OUTPAT REV HCPCS COMBO 1, 172.28,OTHER, 106.26, 242.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15409,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 25.59,,OUTPAT REV HCPCS COMBO 1, 49.86,OTHER, 25.59, 87.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15410,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 106.61,,OUTPAT REV HCPCS COMBO 1, 141.43,OTHER, 85.51, 242.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15411,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.42,,OUTPAT REV HCPCS COMBO 1, 69.71,OTHER, 45.42, 103.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15412,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 120.47,,OUTPAT REV HCPCS COMBO 1, 177.65,OTHER, 120.47, 274.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15413,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 130.87,,OUTPAT REV HCPCS COMBO 1, 189.46,OTHER, 130.87, 298.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15414,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 210.54,,OUTPAT REV HCPCS COMBO 1, 279.93,OTHER, 171.54, 479.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15415,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 197.39,,OUTPAT REV HCPCS COMBO 1, 265.00,OTHER, 171.54, 449.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15416,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 108.18,,OUTPAT REV HCPCS COMBO 1, 149.90,OTHER, 108.18, 246.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15417,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 137.41,,OUTPAT REV HCPCS COMBO 1, 167.02,OTHER, 46.09, 313.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15418,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 57.35,,OUTPAT REV HCPCS COMBO 1, 76.10,OTHER, 46.09, 130.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15419,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 120.09,,OUTPAT REV HCPCS COMBO 1, 147.35,OTHER, 46.09, 273.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15420,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 174.02,,OUTPAT REV HCPCS COMBO 1, 227.22,OTHER, 124.32, 396.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15421,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 234.14,,OUTPAT REV HCPCS COMBO 1, 295.49,OTHER, 124.32, 533.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15422,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 74.67,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 74.67, 170.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15423,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 110.85,,OUTPAT REV HCPCS COMBO 1, 155.48,OTHER, 110.85, 252.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15424,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 17.18,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15425,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 17.18,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15426,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 17.18,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15427,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 8.41,,OUTPAT REV HCPCS COMBO 1, 36.72,OTHER, 8.41, 114.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15428,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 158.39,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 114.13, 360.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15429,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 158.39,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 114.13, 360.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15430,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 391.14,,OUTPAT REV HCPCS COMBO 1, 526.62,OTHER, 346.21, 891.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15431,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15432,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15433,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 132.44,,OUTPAT REV HCPCS COMBO 1, 162.12,OTHER, 49.24, 301.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15434,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 106.64,,OUTPAT REV HCPCS COMBO 1, 140.39,OTHER, 80.99, 243.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15435,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 106.64,,OUTPAT REV HCPCS COMBO 1, 140.39,OTHER, 80.99, 243.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15436,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 136.31,,OUTPAT REV HCPCS COMBO 1, 166.97,OTHER, 51.13, 310.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15437,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 37.67,,OUTPAT REV HCPCS COMBO 1, 54.96,OTHER, 37.67, 85.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15438,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.39,,OUTPAT REV HCPCS COMBO 1, 86.43,OTHER, 51.13, 149.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15439,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 699.47,,OUTPAT REV HCPCS COMBO 1, 950.56,OTHER, 656.16, 1594.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15440,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15441,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 399.90,,OUTPAT REV HCPCS COMBO 1, 545.72,OTHER, 384.68, 911.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15442,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 399.90,,OUTPAT REV HCPCS COMBO 1, 545.72,OTHER, 384.68, 911.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15443,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15444,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15445,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 473.98,,OUTPAT REV HCPCS COMBO 1, 591.97,OTHER, 225.62, 1080.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15446,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15447,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 200.25,,OUTPAT REV HCPCS COMBO 1, 250.40,OTHER, 96.59, 456.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15448,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 200.25,,OUTPAT REV HCPCS COMBO 1, 250.40,OTHER, 96.59, 456.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15449,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15450,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 449.04,,OUTPAT REV HCPCS COMBO 1, 563.65,OTHER, 225.62, 1023.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15451,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15452,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 70.09,,OUTPAT REV HCPCS COMBO 1, 113.30,OTHER, 70.09, 159.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15453,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 70.09,,OUTPAT REV HCPCS COMBO 1, 113.30,OTHER, 70.09, 159.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15454,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15455,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15456,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 215.00,,OUTPAT REV HCPCS COMBO 1, 297.88,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15457,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15458,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 201.13,,OUTPAT REV HCPCS COMBO 1, 262.11,OTHER, 141.55, 458.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15459,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 201.13,,OUTPAT REV HCPCS COMBO 1, 262.11,OTHER, 141.55, 458.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15460,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15461,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15462,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 545.87,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15463,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 545.87,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15464,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 383.08,OTHER, 225.62, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15465,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 545.87,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15466,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15467,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15468,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15469,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15470,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15471,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15472,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15473,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15474,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15475,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15476,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15477,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15478,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 529.82,,OUTPAT REV HCPCS COMBO 1, 655.39,OTHER, 225.62, 1207.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15479,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15480,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1114.13,,OUTPAT REV HCPCS COMBO 1, 1042.14,OTHER, 284.89, 2539.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15481,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 601.78,,OUTPAT REV HCPCS COMBO 1, 1042.14,OTHER, 284.89, 2539.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15482,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 187.48,,OUTPAT REV HCPCS COMBO 1, 184.77,OTHER, 39.56, 427.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15483,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 39.56,,OUTPAT REV HCPCS COMBO 1, 184.77,OTHER, 39.56, 427.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15484,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 452.95,,OUTPAT REV HCPCS COMBO 1, 547.41,OTHER, 138.71, 1032.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15485,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 154.36,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15486,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 154.36,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15487,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 125.79,,OUTPAT REV HCPCS COMBO 1, 199.86,OTHER, 125.79, 286.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15488,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 125.79,,OUTPAT REV HCPCS COMBO 1, 199.86,OTHER, 125.79, 286.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15489,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 263.32,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15490,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 345.29,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15491,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 379.26,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15492,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 263.32,,OUTPAT REV HCPCS COMBO 1, 332.46,OTHER, 140.42, 600.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15493,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 160.29,,OUTPAT REV HCPCS COMBO 1, 239.03,OTHER, 160.29, 365.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15494,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 160.29,,OUTPAT REV HCPCS COMBO 1, 239.03,OTHER, 160.29, 365.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15495,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 174.98,OTHER, 103.88, 239.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15496,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 136.10,OTHER, 76.16, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15497,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 74.39,,OUTPAT REV HCPCS COMBO 1, 140.33,OTHER, 74.39, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15498,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 182.75,,OUTPAT REV HCPCS COMBO 1, 228.33,OTHER, 87.35, 416.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15499,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 22.94,,OUTPAT REV HCPCS COMBO 1, 34.19,OTHER, 22.94, 52.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15500,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15501,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 140.89,,OUTPAT REV HCPCS COMBO 1, 182.46,OTHER, 94.34, 321.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15502,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 140.89,,OUTPAT REV HCPCS COMBO 1, 182.46,OTHER, 94.34, 321.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15503,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 61.67,,OUTPAT REV HCPCS COMBO 1, 125.89,OTHER, 61.67, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15504,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 61.67,,OUTPAT REV HCPCS COMBO 1, 125.89,OTHER, 61.67, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15505,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 316.56,,OUTPAT REV HCPCS COMBO 1, 415.63,OTHER, 235.80, 721.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15506,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1397.50,,OUTPAT REV HCPCS COMBO 1, 1853.96,OTHER, 1121.15, 3185.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15507,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1397.50,,OUTPAT REV HCPCS COMBO 1, 1853.96,OTHER, 1121.15, 3185.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15508,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1677.00,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15509,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1677.00,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15510,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1677.00,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15511,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 116.62,,OUTPAT REV HCPCS COMBO 1, 152.82,OTHER, 85.61, 265.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15512,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 127.40,,OUTPAT REV HCPCS COMBO 1, 165.98,OTHER, 89.47, 290.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15513,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 206.52,,OUTPAT REV HCPCS COMBO 1, 260.74,OTHER, 110.12, 470.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15514,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 206.52,,OUTPAT REV HCPCS COMBO 1, 260.74,OTHER, 110.12, 470.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15515,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 77.49,,OUTPAT REV HCPCS COMBO 1, 96.89,OTHER, 37.34, 176.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15516,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 77.49,,OUTPAT REV HCPCS COMBO 1, 96.89,OTHER, 37.34, 176.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15517,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 245.81,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15518,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 245.81,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15519,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 245.81,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15520,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 70.82,,OUTPAT REV HCPCS COMBO 1, 89.33,OTHER, 37.34, 161.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15521,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 70.85,,OUTPAT REV HCPCS COMBO 1, 89.33,OTHER, 37.34, 161.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15522,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 84.46,,OUTPAT REV HCPCS COMBO 1, 108.89,OTHER, 54.48, 192.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15523,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 84.46,,OUTPAT REV HCPCS COMBO 1, 108.89,OTHER, 54.48, 192.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15524,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 61.89,,OUTPAT REV HCPCS COMBO 1, 92.25,OTHER, 61.89, 141.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15525,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 61.89,,OUTPAT REV HCPCS COMBO 1, 92.25,OTHER, 61.89, 141.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15526,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 66.17,,OUTPAT REV HCPCS COMBO 1, 84.04,OTHER, 37.34, 150.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15527,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 66.17,,OUTPAT REV HCPCS COMBO 1, 84.04,OTHER, 37.34, 150.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15528,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 25.59,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15529,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 25.59,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15530,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 129.36,,OUTPAT REV HCPCS COMBO 1, 159.88,OTHER, 54.48, 294.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15531,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 129.36,,OUTPAT REV HCPCS COMBO 1, 159.88,OTHER, 54.48, 294.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15532,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 73.50,,OUTPAT REV HCPCS COMBO 1, 96.44,OTHER, 54.48, 167.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15533,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 73.50,,OUTPAT REV HCPCS COMBO 1, 96.44,OTHER, 54.48, 167.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15534,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 74.18,,OUTPAT REV HCPCS COMBO 1, 110.56,OTHER, 74.18, 169.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15535,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 74.18,,OUTPAT REV HCPCS COMBO 1, 110.56,OTHER, 74.18, 169.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15536,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 37.82,,OUTPAT REV HCPCS COMBO 1, 47.95,OTHER, 21.01, 86.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15537,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 37.82,,OUTPAT REV HCPCS COMBO 1, 47.95,OTHER, 21.01, 86.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15538,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 41.51,,OUTPAT REV HCPCS COMBO 1, 55.33,OTHER, 34.39, 94.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15539,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 41.51,,OUTPAT REV HCPCS COMBO 1, 55.33,OTHER, 34.39, 94.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15540,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.49,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15541,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.49,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15542,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.49,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15543,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 180.60,,OUTPAT REV HCPCS COMBO 1, 142.33,OTHER, 28.82, 411.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15544,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 57.99,,OUTPAT REV HCPCS COMBO 1, 142.33,OTHER, 28.82, 411.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15545,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 57.99,,OUTPAT REV HCPCS COMBO 1, 72.71,OTHER, 28.82, 132.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15546,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 52.84,,OUTPAT REV HCPCS COMBO 1, 74.33,OTHER, 52.80, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15547,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 52.80,,OUTPAT REV HCPCS COMBO 1, 74.33,OTHER, 52.80, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15548,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 52.84,,OUTPAT REV HCPCS COMBO 1, 74.35,OTHER, 52.84, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15549,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 56.36,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15550,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 56.36,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15551,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 56.36,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15552,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 40.91,,OUTPAT REV HCPCS COMBO 1, 60.80,OTHER, 40.91, 93.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15553,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 40.91,,OUTPAT REV HCPCS COMBO 1, 60.80,OTHER, 40.91, 93.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15554,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 29.08,,OUTPAT REV HCPCS COMBO 1, 47.68,OTHER, 29.08, 66.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15555,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 76.97,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15556,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 76.97,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15557,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 76.97,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15558,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 92.45,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15559,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 92.45,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15560,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 92.45,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15561,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 52.75,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15562,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 52.75,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15563,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 52.75,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15564,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 18.92,,OUTPAT REV HCPCS COMBO 1, 30.33,OTHER, 18.92, 43.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15565,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 113.97,,OUTPAT REV HCPCS COMBO 1, 178.52,OTHER, 113.97, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15566,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 135.24,,OUTPAT REV HCPCS COMBO 1, 202.67,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15567,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 128.04,,OUTPAT REV HCPCS COMBO 1, 194.50,OTHER, 128.04, 291.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15568,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 63.79,,OUTPAT REV HCPCS COMBO 1, 106.37,OTHER, 63.79, 145.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15569,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 109.36,,OUTPAT REV HCPCS COMBO 1, 173.75,OTHER, 109.36, 249.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15570,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 115.60,,OUTPAT REV HCPCS COMBO 1, 180.83,OTHER, 115.60, 263.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15571,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 136.43,,OUTPAT REV HCPCS COMBO 1, 204.49,OTHER, 136.43, 310.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15572,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.89,,OUTPAT REV HCPCS COMBO 1, 108.91,OTHER, 65.89, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15573,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 51.91,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15574,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 51.91,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15575,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 51.91,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15576,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 31.56,,OUTPAT REV HCPCS COMBO 1, 44.69,OTHER, 31.56, 71.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15577,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 54.89,,OUTPAT REV HCPCS COMBO 1, 78.22,OTHER, 54.89, 125.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15578,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 54.89,,OUTPAT REV HCPCS COMBO 1, 78.22,OTHER, 54.89, 125.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15579,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 38.11,,OUTPAT REV HCPCS COMBO 1, 59.17,OTHER, 38.11, 86.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15580,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 49.88,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15581,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 49.88,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15582,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 49.88,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15583,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15584,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 61.82,,OUTPAT REV HCPCS COMBO 1, 93.12,OTHER, 61.82, 140.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15585,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 52.03,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 52.03, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15586,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 113.97,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 52.03, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15587,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 53.32,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15588,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 53.32,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15589,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 53.32,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15590,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15591,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15592,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 60.63,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15593,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15594,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 60.63,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15595,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15596,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15597,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 129.00,,OUTPAT REV HCPCS COMBO 1, 192.27,OTHER, 129.00, 294.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15598,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15599,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15600,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 145.27,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15601,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 63.96,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15602,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 63.96,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15603,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 108.39,,OUTPAT REV HCPCS COMBO 1, 161.56,OTHER, 108.39, 247.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15604,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 108.39,,OUTPAT REV HCPCS COMBO 1, 161.56,OTHER, 108.39, 247.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15605,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15606,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15607,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 211.26,,OUTPAT REV HCPCS COMBO 1, 314.88,OTHER, 211.26, 481.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15608,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 211.26,,OUTPAT REV HCPCS COMBO 1, 314.88,OTHER, 211.26, 481.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15609,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 20.47,,OUTPAT REV HCPCS COMBO 1, 30.51,OTHER, 20.47, 46.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15610,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 44.59,,OUTPAT REV HCPCS COMBO 1, 66.46,OTHER, 44.59, 101.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15611,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 44.59,,OUTPAT REV HCPCS COMBO 1, 66.46,OTHER, 44.59, 101.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15612,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 74.56,,OUTPAT REV HCPCS COMBO 1, 111.13,OTHER, 74.56, 169.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15613,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 74.56,,OUTPAT REV HCPCS COMBO 1, 111.13,OTHER, 74.56, 169.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15614,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 110.02,,OUTPAT REV HCPCS COMBO 1, 163.98,OTHER, 110.02, 250.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15615,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 110.02,,OUTPAT REV HCPCS COMBO 1, 163.98,OTHER, 110.02, 250.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15616,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 147.30,,OUTPAT REV HCPCS COMBO 1, 219.55,OTHER, 147.30, 335.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15617,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 147.30,,OUTPAT REV HCPCS COMBO 1, 219.55,OTHER, 147.30, 335.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15618,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15619,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15620,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15621,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15622,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15623,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 115.64,,OUTPAT REV HCPCS COMBO 1, 149.74,OTHER, 77.35, 263.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15624,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 115.64,,OUTPAT REV HCPCS COMBO 1, 149.74,OTHER, 77.35, 263.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15625,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15626,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15627,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 178.88,,OUTPAT REV HCPCS COMBO 1, 233.57,OTHER, 127.82, 407.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15628,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 178.88,,OUTPAT REV HCPCS COMBO 1, 233.57,OTHER, 127.82, 407.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15629,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15630,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15631,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 282.66,,OUTPAT REV HCPCS COMBO 1, 369.55,OTHER, 203.96, 644.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15632,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 282.66,,OUTPAT REV HCPCS COMBO 1, 369.55,OTHER, 203.96, 644.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15633,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15634,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15635,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 443.36,,OUTPAT REV HCPCS COMBO 1, 580.80,OTHER, 324.71, 1010.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15636,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 443.36,,OUTPAT REV HCPCS COMBO 1, 580.80,OTHER, 324.71, 1010.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15637,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15638,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15639,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 739.51,,OUTPAT REV HCPCS COMBO 1, 954.02,OTHER, 479.76, 1685.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15640,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 739.51,,OUTPAT REV HCPCS COMBO 1, 954.02,OTHER, 479.76, 1685.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15641,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15642,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1182.84,,OUTPAT REV HCPCS COMBO 1, 1514.86,OTHER, 720.78, 2695.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15643,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 433.62,,OUTPAT REV HCPCS COMBO 1, 646.30,OTHER, 433.62, 988.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15644,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 19.23,OTHER, 12.90, 29.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15645,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 72.00,,OUTPAT REV HCPCS COMBO 1, 107.32,OTHER, 72.00, 164.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15646,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 72.00,,OUTPAT REV HCPCS COMBO 1, 107.32,OTHER, 72.00, 164.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15647,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 113.31,,OUTPAT REV HCPCS COMBO 1, 167.97,OTHER, 113.31, 258.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15648,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 118.06,,OUTPAT REV HCPCS COMBO 1, 173.37,OTHER, 118.06, 269.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15649,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 123.17,,OUTPAT REV HCPCS COMBO 1, 179.18,OTHER, 123.17, 280.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15650,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 139.26,,OUTPAT REV HCPCS COMBO 1, 197.44,OTHER, 139.26, 317.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15651,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 135.24,,OUTPAT REV HCPCS COMBO 1, 192.88,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15652,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 156.07,,OUTPAT REV HCPCS COMBO 1, 232.62,OTHER, 156.07, 355.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15653,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15654,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 101.97,,OUTPAT REV HCPCS COMBO 1, 155.10,OTHER, 101.97, 232.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15655,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 108.92,,OUTPAT REV HCPCS COMBO 1, 162.99,OTHER, 108.92, 248.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15656,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 118.79,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15657,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 118.79,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15658,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 118.79,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15659,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 121.35,,OUTPAT REV HCPCS COMBO 1, 177.10,OTHER, 121.35, 276.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15660,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 129.39,,OUTPAT REV HCPCS COMBO 1, 192.85,OTHER, 129.39, 294.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15661,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 139.26,,OUTPAT REV HCPCS COMBO 1, 207.56,OTHER, 139.26, 317.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15662,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 37.28,,OUTPAT REV HCPCS COMBO 1, 55.57,OTHER, 37.28, 84.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15663,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 63.96,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15664,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 30.10,,OUTPAT REV HCPCS COMBO 1, 44.86,OTHER, 30.10, 68.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15665,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 114.40,,OUTPAT REV HCPCS COMBO 1, 170.52,OTHER, 114.40, 260.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15666,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 22.74,,OUTPAT REV HCPCS COMBO 1, 33.14,OTHER, 22.74, 51.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15667,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.14,,OUTPAT REV HCPCS COMBO 1, 39.28,OTHER, 28.14, 64.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15668,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 40.58,,OUTPAT REV HCPCS COMBO 1, 60.49,OTHER, 40.58, 92.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15669,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 9.46,,OUTPAT REV HCPCS COMBO 1, 14.10,OTHER, 9.46, 21.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15670,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 9.46,,OUTPAT REV HCPCS COMBO 1, 54.72,OTHER, 9.46, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15671,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 63.96,,OUTPAT REV HCPCS COMBO 1, 54.72,OTHER, 9.46, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15672,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 109.65,,OUTPAT REV HCPCS COMBO 1, 148.65,OTHER, 101.33, 249.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15673,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 118.25,,OUTPAT REV HCPCS COMBO 1, 166.04,OTHER, 118.25, 269.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15674,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 5.48,,OUTPAT REV HCPCS COMBO 1, 8.17,OTHER, 5.48, 12.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15675,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 5.48,,OUTPAT REV HCPCS COMBO 1, 8.17,OTHER, 5.48, 12.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15676,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 165.55,,OUTPAT REV HCPCS COMBO 1, 350.13,OTHER, 165.55, 680.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15677,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 165.55,,OUTPAT REV HCPCS COMBO 1, 350.13,OTHER, 165.55, 680.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15678,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 261.01,,OUTPAT REV HCPCS COMBO 1, 553.11,OTHER, 261.01, 1078.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15679,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 261.01,,OUTPAT REV HCPCS COMBO 1, 553.11,OTHER, 261.01, 1078.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15680,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 152.65,,OUTPAT REV HCPCS COMBO 1, 308.45,OTHER, 152.65, 567.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15681,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 152.65,,OUTPAT REV HCPCS COMBO 1, 308.45,OTHER, 152.65, 567.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15682,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 220.16,,OUTPAT REV HCPCS COMBO 1, 466.19,OTHER, 220.16, 907.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15683,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 220.16,,OUTPAT REV HCPCS COMBO 1, 466.19,OTHER, 220.16, 907.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15684,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 377.54,,OUTPAT REV HCPCS COMBO 1, 562.72,OTHER, 377.54, 860.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15685,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 377.54,,OUTPAT REV HCPCS COMBO 1, 562.72,OTHER, 377.54, 860.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15686,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 419.25,,OUTPAT REV HCPCS COMBO 1, 624.89,OTHER, 419.25, 955.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15687,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 419.25,,OUTPAT REV HCPCS COMBO 1, 624.89,OTHER, 419.25, 955.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15688,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 58.48,,OUTPAT REV HCPCS COMBO 1, 87.16,OTHER, 58.48, 133.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15689,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 27.52,,OUTPAT REV HCPCS COMBO 1, 41.02,OTHER, 27.52, 62.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15690,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15691,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1288.28,,OUTPAT REV HCPCS COMBO 1, 1648.47,OTHER, 779.04, 2936.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15692,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1288.28,,OUTPAT REV HCPCS COMBO 1, 1648.47,OTHER, 779.04, 2936.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15693,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1402.23,,OUTPAT REV HCPCS COMBO 1, 1777.88,OTHER, 779.04, 3195.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15694,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1402.23,,OUTPAT REV HCPCS COMBO 1, 1777.88,OTHER, 779.04, 3195.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15695,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15696,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15697,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15698,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1097.72,OTHER, 508.57, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15699,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1097.72,OTHER, 508.57, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15700,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1162.11,OTHER, 779.04, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15701,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1162.11,OTHER, 779.04, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15702,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 8.23,,OUTPAT REV HCPCS COMBO 1, 9.74,OTHER, 1.66, 18.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15703,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 48.44,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15704,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 11.82,OTHER, 2.58, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15705,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 38.74,,OUTPAT REV HCPCS COMBO 1, 57.75,OTHER, 38.74, 88.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15706,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 20.10,,OUTPAT REV HCPCS COMBO 1, 29.96,OTHER, 20.10, 45.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15707,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 71.08,,OUTPAT REV HCPCS COMBO 1, 88.75,OTHER, 33.71, 162.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15708,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 58.81,OTHER, 33.71, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15709,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 168.13,,OUTPAT REV HCPCS COMBO 1, 250.60,OTHER, 168.13, 383.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15710,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 231.89,OTHER, 165.06, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15711,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 231.89,OTHER, 165.06, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15712,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 18.28,,OUTPAT REV HCPCS COMBO 1, 35.44,OTHER, 18.28, 61.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15713,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 26.32,,OUTPAT REV HCPCS COMBO 1, 44.57,OTHER, 26.32, 61.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15714,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 29.24,,OUTPAT REV HCPCS COMBO 1, 43.58,OTHER, 29.24, 66.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15715,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15716,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 111.71,,OUTPAT REV HCPCS COMBO 1, 166.51,OTHER, 111.71, 254.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15717,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 40.32,,OUTPAT REV HCPCS COMBO 1, 60.10,OTHER, 40.32, 91.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15718,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 3.30,,OUTPAT REV HCPCS COMBO 1, 4.92,OTHER, 3.30, 7.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15719,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 3.20,,OUTPAT REV HCPCS COMBO 1, 4.77,OTHER, 3.20, 7.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15720,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 8.74,,OUTPAT REV HCPCS COMBO 1, 13.02,OTHER, 8.74, 19.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15721,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 90.30,,OUTPAT REV HCPCS COMBO 1, 134.59,OTHER, 90.30, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15722,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .91,,OUTPAT REV HCPCS COMBO 1, 1.36,OTHER, .91, 2.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15723,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1.41,,OUTPAT REV HCPCS COMBO 1, 2.10,OTHER, 1.41, 3.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15724,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 17.38,,OUTPAT REV HCPCS COMBO 1, 25.91,OTHER, 17.38, 39.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15725,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 62.40,,OUTPAT REV HCPCS COMBO 1, 93.00,OTHER, 62.40, 142.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15726,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .98,,OUTPAT REV HCPCS COMBO 1, 1.46,OTHER, .98, 2.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15727,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .69,,OUTPAT REV HCPCS COMBO 1, 1.03,OTHER, .69, 1.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15728,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 3.46,,OUTPAT REV HCPCS COMBO 1, 5.15,OTHER, 3.46, 7.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15729,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 7.69,,OUTPAT REV HCPCS COMBO 1, 11.46,OTHER, 7.69, 17.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15730,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2.94,,OUTPAT REV HCPCS COMBO 1, 4.38,OTHER, 2.94, 6.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15731,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1.72,,OUTPAT REV HCPCS COMBO 1, 2.56,OTHER, 1.72, 3.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15732,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 5.02,,OUTPAT REV HCPCS COMBO 1, 7.91,OTHER, 5.02, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15733,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 5.59,,OUTPAT REV HCPCS COMBO 1, 7.91,OTHER, 5.02, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15734,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 29.38,,OUTPAT REV HCPCS COMBO 1, 43.79,OTHER, 29.38, 66.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15735,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 15.45,,OUTPAT REV HCPCS COMBO 1, 23.02,OTHER, 15.45, 35.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15736,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 4.52,,OUTPAT REV HCPCS COMBO 1, 6.74,OTHER, 4.52, 10.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15737,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 3.49,,OUTPAT REV HCPCS COMBO 1, 5.20,OTHER, 3.49, 7.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15738,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 171.57,,OUTPAT REV HCPCS COMBO 1, 575.18,OTHER, 171.57, 1597.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15739,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 171.57,,OUTPAT REV HCPCS COMBO 1, 690.66,OTHER, 171.57, 2082.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15740,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 171.57,,OUTPAT REV HCPCS COMBO 1, 656.15,OTHER, 171.57, 1937.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15741,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 171.57,,OUTPAT REV HCPCS COMBO 1, 607.70,OTHER, 171.57, 1734.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15742,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 214.57,,OUTPAT REV HCPCS COMBO 1, 735.35,OTHER, 214.57, 2065.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15743,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 367.65,,OUTPAT REV HCPCS COMBO 1, 421.89,OTHER, 18.42, 837.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15744,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2.06,,OUTPAT REV HCPCS COMBO 1, 3.08,OTHER, 2.06, 4.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15745,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15746,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15747,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15748,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15749,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15750,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15751,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15752,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15753,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15754,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15755,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15756,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15757,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15758,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15759,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15760,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15761,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15762,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15763,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15764,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15765,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15766,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15767,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15768,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15769,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15770,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15771,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15772,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15773,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15774,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15775,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15776,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15777,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15778,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15779,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15780,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15781,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.69,,OUTPAT REV HCPCS COMBO 1, 62.01,OTHER, 42.53, 104.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15782,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 49.02,,OUTPAT REV HCPCS COMBO 1, 73.06,OTHER, 49.02, 111.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15783,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15784,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 215.00,,OUTPAT REV HCPCS COMBO 1, 320.46,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15785,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 18.06,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15786,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15787,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 15.05,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15788,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15789,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 11.61,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15790,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15791,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15792,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15793,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15794,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15795,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1.94,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15796,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15797,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15798,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15799,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 79.09,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15800,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15801,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 77.40,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15802,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 24.94,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15803,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 24.94,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15804,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 142.83,,OUTPAT REV HCPCS COMBO 1, 212.89,OTHER, 142.83, 325.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15805,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 52.37,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15806,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15807,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 423.39,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15808,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 308.33,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15809,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 3.87,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15810,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15811,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15812,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15813,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15814,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15815,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15816,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15817,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15818,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15819,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15820,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 43.86,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15821,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 30.89,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15822,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 30.89,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15823,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15824,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 59.16,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15825,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15826,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15827,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15828,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15829,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 7.74,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15830,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 10.32,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15831,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15832,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 12.26,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15833,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 12.26,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15834,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15835,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15836,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15837,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15838,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15839,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15840,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 19.99,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15841,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 4.30,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15842,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 2.02,OTHER, 1.35, 3.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15843,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 215.43,,OUTPAT REV HCPCS COMBO 1, 321.10,OTHER, 215.43, 490.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15844,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 245.96,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15845,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15846,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15847,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15848,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15849,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15850,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15851,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15852,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 14.63,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15853,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 65.44,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15854,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 61.34,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15855,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 40.07,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15856,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 36.78,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15857,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 111.92,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15858,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 3270.45,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15859,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 19.44,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15860,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15861,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15862,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15863,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15864,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15865,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15866,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 1032.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15867,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15868,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15869,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15870,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15871,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15872,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15873,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 602.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15874,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 602.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15875,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 602.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15876,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15877,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15878,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15879,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15880,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15881,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 28.87,,OUTPAT REV HCPCS COMBO 1, 43.03,OTHER, 28.87, 65.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15882,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 4.30,,OUTPAT REV HCPCS COMBO 1, 6.41,OTHER, 4.30, 9.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15883,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2494.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15884,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2064.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15885,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2064.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15886,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, 2064.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15887,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15888,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15889,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15890,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15891,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15892,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15893,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15894,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15895,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15896,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15897,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15898,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15899,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15900,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15901,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15902,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15903,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15904,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15905,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15906,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15907,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15908,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15909,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15910,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15911,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15912,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15913,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15914,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_HUMANA,HUMANA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15915,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15916,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15917,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15918,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15919,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15920,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15921,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15922,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15923,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15924,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15925,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15926,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15927,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15928,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15929,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15930,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15931,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15932,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15933,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 219.79,,OUTPAT REV HCPCS COMBO 1, 271.70,OTHER, 142.76, 477.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15934,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 219.79,,OUTPAT REV HCPCS COMBO 1, 271.70,OTHER, 142.76, 477.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15935,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 124.73,,OUTPAT REV HCPCS COMBO 1, 168.89,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15936,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15937,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 221.79,,OUTPAT REV HCPCS COMBO 1, 273.87,OTHER, 142.76, 481.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15938,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15939,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 163.49,,OUTPAT REV HCPCS COMBO 1, 242.16,OTHER, 155.70, 354.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15940,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15941,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15942,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15943,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15944,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15945,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15946,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15947,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15948,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15949,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15950,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15951,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15952,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15953,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15954,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15955,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15956,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15957,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15958,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15959,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15960,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15961,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15962,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15963,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15964,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15965,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15966,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15967,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15968,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15969,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15970,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15971,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15972,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15973,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15974,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15975,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15976,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15977,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15978,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15979,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15980,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15981,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15982,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15983,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 152.56,,OUTPAT REV HCPCS COMBO 1, 185.53,OTHER, 86.20, 331.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15984,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15985,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15986,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15987,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15988,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15989,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15990,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 173.26,,OUTPAT REV HCPCS COMBO 1, 278.63,OTHER, 165.01, 383.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15991,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 311.01,,OUTPAT REV HCPCS COMBO 1, 427.61,OTHER, 296.20, 675.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15992,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 188.21,,OUTPAT REV HCPCS COMBO 1, 237.66,OTHER, 143.26, 408.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15993,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 202.99,,OUTPAT REV HCPCS COMBO 1, 253.66,OTHER, 143.26, 440.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15994,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 220.11,,OUTPAT REV HCPCS COMBO 1, 272.17,OTHER, 143.26, 477.75,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15995,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 200.90,,OUTPAT REV HCPCS COMBO 1, 251.39,OTHER, 143.26, 436.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15996,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 15997,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 213.07,,OUTPAT REV HCPCS COMBO 1, 264.56,OTHER, 143.26, 462.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15998,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 215.23,,OUTPAT REV HCPCS COMBO 1, 306.35,OTHER, 204.98, 467.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 15999,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16000,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16001,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 241.75,,OUTPAT REV HCPCS COMBO 1, 293.08,OTHER, 132.82, 524.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16002,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 878.56,,OUTPAT REV HCPCS COMBO 1, 1023.77,OTHER, 309.01, 1906.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16003,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16004,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1479.23,,OUTPAT REV HCPCS COMBO 1, 1703.49,OTHER, 435.32, 3210.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16005,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16006,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16007,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16008,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16009,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 152.56,,OUTPAT REV HCPCS COMBO 1, 200.99,OTHER, 145.30, 331.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16010,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16011,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16012,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16013,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16014,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16015,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16016,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16017,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 59.87,,OUTPAT REV HCPCS COMBO 1, 124.43,OTHER, 57.02, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16018,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 55.99,,OUTPAT REV HCPCS COMBO 1, 120.23,OTHER, 53.32, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16019,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 65.24,,OUTPAT REV HCPCS COMBO 1, 130.25,OTHER, 62.14, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16020,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 65.24,,OUTPAT REV HCPCS COMBO 1, 130.25,OTHER, 62.14, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16021,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16022,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16023,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 356.78,,OUTPAT REV HCPCS COMBO 1, 424.57,OTHER, 162.56, 774.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16024,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 273.86,,OUTPAT REV HCPCS COMBO 1, 334.89,OTHER, 162.56, 594.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16025,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 521.41,,OUTPAT REV HCPCS COMBO 1, 675.88,OTHER, 470.23, 1131.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16026,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 426.31,,OUTPAT REV HCPCS COMBO 1, 499.77,OTHER, 162.56, 925.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16027,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 426.31,,OUTPAT REV HCPCS COMBO 1, 499.77,OTHER, 162.56, 925.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16028,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 156.24,,OUTPAT REV HCPCS COMBO 1, 207.69,OTHER, 148.80, 339.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16029,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 156.24,,OUTPAT REV HCPCS COMBO 1, 207.69,OTHER, 148.80, 339.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16030,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 140.63,,OUTPAT REV HCPCS COMBO 1, 176.70,OTHER, 103.34, 305.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16031,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 510.17,,OUTPAT REV HCPCS COMBO 1, 596.69,OTHER, 188.66, 1107.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16032,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 510.17,,OUTPAT REV HCPCS COMBO 1, 596.69,OTHER, 188.66, 1107.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16033,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 887.62,,OUTPAT REV HCPCS COMBO 1, 1089.64,OTHER, 544.52, 1926.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16034,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 15.80,,OUTPAT REV HCPCS COMBO 1, 22.43,OTHER, 15.05, 34.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16035,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 14.02,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16036,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 14.02,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16037,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 14.02,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16038,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 14.02,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16039,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 14.02,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16040,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16041,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 11.29,,OUTPAT REV HCPCS COMBO 1, 16.02,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16042,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 462.39,,OUTPAT REV HCPCS COMBO 1, 579.04,OTHER, 331.58, 1003.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16043,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16044,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16045,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16046,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16047,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16048,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 109.08,,OUTPAT REV HCPCS COMBO 1, 124.21,OTHER, 26.22, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16049,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 109.08,,OUTPAT REV HCPCS COMBO 1, 124.21,OTHER, 26.22, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16050,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16051,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16052,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16053,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16054,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16055,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16056,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16057,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16058,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16059,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16060,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16061,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16062,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 526.55,,OUTPAT REV HCPCS COMBO 1, 718.33,OTHER, 501.48, 1142.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16063,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16064,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16065,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16066,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16067,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16068,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16069,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16070,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16071,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16072,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16073,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16074,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16075,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16076,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16077,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16078,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16079,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16080,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16081,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16082,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16083,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16084,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16085,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16086,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16087,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16088,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 181.93,,OUTPAT REV HCPCS COMBO 1, 242.39,OTHER, 173.27, 394.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16089,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 181.93,,OUTPAT REV HCPCS COMBO 1, 242.39,OTHER, 173.27, 394.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16090,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16091,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 101.59,,OUTPAT REV HCPCS COMBO 1, 199.77,OTHER, 96.75, 377.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16092,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 101.59,,OUTPAT REV HCPCS COMBO 1, 266.50,OTHER, 96.75, 657.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16093,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1552.26,,OUTPAT REV HCPCS COMBO 1, 2146.91,OTHER, 1478.34, 3369.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16094,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1552.26,,OUTPAT REV HCPCS COMBO 1, 2146.91,OTHER, 1478.34, 3369.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16095,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 506.97,,OUTPAT REV HCPCS COMBO 1, 719.65,OTHER, 482.83, 1100.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16096,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 906.86,,OUTPAT REV HCPCS COMBO 1, 1287.31,OTHER, 863.68, 1968.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16097,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 204.94,,OUTPAT REV HCPCS COMBO 1, 290.91,OTHER, 195.18, 444.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16098,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16099,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 117.90,,OUTPAT REV HCPCS COMBO 1, 162.43,OTHER, 112.28, 255.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16100,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 102.08,,OUTPAT REV HCPCS COMBO 1, 145.32,OTHER, 97.21, 221.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16101,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 65.20,,OUTPAT REV HCPCS COMBO 1, 116.13,OTHER, 62.09, 191.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16102,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 53.73,,OUTPAT REV HCPCS COMBO 1, 76.24,OTHER, 51.17, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16103,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 96.20,,OUTPAT REV HCPCS COMBO 1, 124.60,OTHER, 86.34, 208.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16104,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16105,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.83,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16106,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16107,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 61.86,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16108,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16109,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 118.86,,OUTPAT REV HCPCS COMBO 1, 161.46,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16110,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16111,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.83,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16112,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16113,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 128.57,,OUTPAT REV HCPCS COMBO 1, 171.96,OTHER, 122.45, 279.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16114,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16115,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 99.10,,OUTPAT REV HCPCS COMBO 1, 127.74,OTHER, 86.34, 215.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16116,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16117,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 144.87,,OUTPAT REV HCPCS COMBO 1, 189.58,OTHER, 137.97, 314.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16118,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16119,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 89.09,,OUTPAT REV HCPCS COMBO 1, 116.92,OTHER, 84.85, 193.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16120,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16121,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 246.53,,OUTPAT REV HCPCS COMBO 1, 299.54,OTHER, 138.19, 535.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16122,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16123,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 173.95,,OUTPAT REV HCPCS COMBO 1, 221.04,OTHER, 138.19, 377.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16124,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16125,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 133.64,,OUTPAT REV HCPCS COMBO 1, 177.44,OTHER, 127.28, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16126,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16127,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 46.83,,OUTPAT REV HCPCS COMBO 1, 71.21,OTHER, 44.60, 101.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16128,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16129,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 159.96,,OUTPAT REV HCPCS COMBO 1, 193.56,OTHER, 86.34, 347.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16130,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16131,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 187.64,,OUTPAT REV HCPCS COMBO 1, 223.50,OTHER, 86.34, 407.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16132,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1322.06,,OUTPAT REV HCPCS COMBO 1, 1313.91,OTHER, 283.82, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16133,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 982.68,,OUTPAT REV HCPCS COMBO 1, 1313.91,OTHER, 283.82, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16134,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16135,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16136,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1010.73,,OUTPAT REV HCPCS COMBO 1, 1196.04,OTHER, 432.18, 2193.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16137,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1010.73,,OUTPAT REV HCPCS COMBO 1, 1196.04,OTHER, 432.18, 2193.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16138,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16139,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16140,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1322.06,,OUTPAT REV HCPCS COMBO 1, 1545.39,OTHER, 485.27, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16141,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1322.06,,OUTPAT REV HCPCS COMBO 1, 1545.39,OTHER, 485.27, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16142,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16143,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16144,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 820.71,,OUTPAT REV HCPCS COMBO 1, 955.20,OTHER, 283.82, 1781.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16145,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16146,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 544.08,,OUTPAT REV HCPCS COMBO 1, 691.35,OTHER, 432.18, 1180.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16147,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16148,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 713.37,,OUTPAT REV HCPCS COMBO 1, 887.08,OTHER, 485.27, 1548.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16149,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16150,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 770.71,,OUTPAT REV HCPCS COMBO 1, 901.22,OTHER, 283.82, 1673.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16151,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 770.88,,OUTPAT REV HCPCS COMBO 1, 901.22,OTHER, 283.82, 1673.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16152,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16153,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16154,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 881.18,,OUTPAT REV HCPCS COMBO 1, 1055.93,OTHER, 432.18, 1912.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16155,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1109.33,,OUTPAT REV HCPCS COMBO 1, 1302.68,OTHER, 432.18, 2407.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16156,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16157,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16158,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 367.52,,OUTPAT REV HCPCS COMBO 1, 513.03,OTHER, 350.02, 797.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16159,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16160,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1130.81,,OUTPAT REV HCPCS COMBO 1, 1290.59,OTHER, 283.82, 2454.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16161,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16162,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1176.02,,OUTPAT REV HCPCS COMBO 1, 1374.81,OTHER, 432.18, 2552.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16163,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16164,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1063.69,,OUTPAT REV HCPCS COMBO 1, 1265.96,OTHER, 485.27, 2308.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16165,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16166,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 885.96,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16167,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 885.96,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16168,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 885.96,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16169,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16170,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16171,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16172,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1065.95,,OUTPAT REV HCPCS COMBO 1, 1270.81,OTHER, 495.38, 2313.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16173,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16174,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1383.25,,OUTPAT REV HCPCS COMBO 1, 1681.52,OTHER, 779.04, 3002.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16175,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16176,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1020.57,,OUTPAT REV HCPCS COMBO 1, 1224.87,OTHER, 508.57, 2215.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16177,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16178,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1088.57,,OUTPAT REV HCPCS COMBO 1, 1324.21,OTHER, 616.91, 2362.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16179,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16180,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1245.91,,OUTPAT REV HCPCS COMBO 1, 1532.99,OTHER, 779.04, 2704.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16181,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16182,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1028.63,,OUTPAT REV HCPCS COMBO 1, 1233.59,OTHER, 508.57, 2232.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16183,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16184,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1025.81,,OUTPAT REV HCPCS COMBO 1, 1256.33,OTHER, 616.91, 2226.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16185,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16186,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1179.43,,OUTPAT REV HCPCS COMBO 1, 1461.09,OTHER, 779.04, 2560.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16187,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16188,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1195.13,,OUTPAT REV HCPCS COMBO 1, 1413.66,OTHER, 508.57, 2594.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16189,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16190,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1845.24,,OUTPAT REV HCPCS COMBO 1, 2181.19,OTHER, 779.04, 4005.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16191,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1845.24,,OUTPAT REV HCPCS COMBO 1, 2181.19,OTHER, 779.04, 4005.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16192,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16193,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16194,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.83,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16195,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.83,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16196,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.83,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16197,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.83,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16198,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16199,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16200,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16201,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16202,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.83,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16203,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16204,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.83,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16205,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.83,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16206,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16207,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16208,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 204.80,,OUTPAT REV HCPCS COMBO 1, 242.05,OTHER, 86.34, 444.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16209,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 206.15,,OUTPAT REV HCPCS COMBO 1, 243.52,OTHER, 86.34, 447.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16210,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16211,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16212,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 167.57,,OUTPAT REV HCPCS COMBO 1, 214.14,OTHER, 138.19, 363.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16213,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 191.51,,OUTPAT REV HCPCS COMBO 1, 240.03,OTHER, 138.19, 415.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16214,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16215,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16216,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 199.68,,OUTPAT REV HCPCS COMBO 1, 248.87,OTHER, 138.19, 433.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16217,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16218,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 133.64,,OUTPAT REV HCPCS COMBO 1, 165.10,OTHER, 86.34, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16219,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16220,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.83,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16221,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16222,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1057.59,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16223,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1057.59,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16224,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1057.59,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16225,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16226,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16227,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1057.59,,OUTPAT REV HCPCS COMBO 1, 1356.87,OTHER, 432.18, 2737.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16228,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1261.27,,OUTPAT REV HCPCS COMBO 1, 1356.87,OTHER, 432.18, 2737.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16229,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16230,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1573.41,,OUTPAT REV HCPCS COMBO 1, 1817.25,OTHER, 485.27, 3415.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16231,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16232,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1057.59,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16233,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1057.59,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16234,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1057.59,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16235,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16236,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16237,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16238,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2248.48,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16239,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1515.09,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16240,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1515.09,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16241,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1515.09,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16242,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1515.09,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16243,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16244,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16245,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16246,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16247,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 571.60,,OUTPAT REV HCPCS COMBO 1, 1310.99,OTHER, 544.38, 2768.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16248,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1275.49,,OUTPAT REV HCPCS COMBO 1, 1310.99,OTHER, 544.38, 2768.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16249,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16250,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16251,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 137.26,,OUTPAT REV HCPCS COMBO 1, 169.01,OTHER, 86.34, 297.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16252,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 137.26,,OUTPAT REV HCPCS COMBO 1, 169.01,OTHER, 86.34, 297.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16253,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16254,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16255,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 198.56,,OUTPAT REV HCPCS COMBO 1, 247.65,OTHER, 138.19, 430.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16256,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16257,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 293.75,,OUTPAT REV HCPCS COMBO 1, 350.60,OTHER, 138.19, 637.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16258,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16259,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 323.36,,OUTPAT REV HCPCS COMBO 1, 382.63,OTHER, 138.19, 701.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16260,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16261,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 240.95,,OUTPAT REV HCPCS COMBO 1, 293.50,OTHER, 138.19, 522.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16262,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16263,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 215.39,,OUTPAT REV HCPCS COMBO 1, 265.86,OTHER, 138.19, 467.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16264,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16265,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 118.86,,OUTPAT REV HCPCS COMBO 1, 161.46,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16266,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16267,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 112.88,,OUTPAT REV HCPCS COMBO 1, 142.64,OTHER, 86.34, 245.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16268,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16269,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.83,,OUTPAT REV HCPCS COMBO 1, 63.06,OTHER, 36.98, 88.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16270,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 118.86,,OUTPAT REV HCPCS COMBO 1, 163.44,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16271,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16272,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 209.27,,OUTPAT REV HCPCS COMBO 1, 259.24,OTHER, 138.19, 454.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16273,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16274,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 123.90,,OUTPAT REV HCPCS COMBO 1, 166.91,OTHER, 118.00, 268.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16275,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16276,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 345.97,,OUTPAT REV HCPCS COMBO 1, 407.08,OTHER, 138.19, 750.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16277,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16278,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1286.87,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16279,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1286.87,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16280,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1286.87,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16281,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16282,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16283,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16284,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 507.94,,OUTPAT REV HCPCS COMBO 1, 664.89,OTHER, 483.75, 1102.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16285,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16286,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1462.30,,OUTPAT REV HCPCS COMBO 1, 1649.11,OTHER, 283.82, 3173.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16287,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1462.30,,OUTPAT REV HCPCS COMBO 1, 1649.11,OTHER, 283.82, 3173.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16288,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16289,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16290,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1444.80,,OUTPAT REV HCPCS COMBO 1, 1665.51,OTHER, 432.18, 3136.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16291,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16292,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1268.20,,OUTPAT REV HCPCS COMBO 1, 1439.18,OTHER, 283.82, 2752.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16293,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16294,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1432.85,,OUTPAT REV HCPCS COMBO 1, 1652.58,OTHER, 432.18, 3110.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16295,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16296,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1354.50,,OUTPAT REV HCPCS COMBO 1, 1580.48,OTHER, 485.27, 2940.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16297,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16298,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1471.24,,OUTPAT REV HCPCS COMBO 1, 1712.29,OTHER, 508.57, 3193.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16299,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16300,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1639.97,,OUTPAT REV HCPCS COMBO 1, 1894.78,OTHER, 508.57, 3559.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16301,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16302,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1439.47,,OUTPAT REV HCPCS COMBO 1, 1677.93,OTHER, 508.57, 3124.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16303,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16304,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1788.48,,OUTPAT REV HCPCS COMBO 1, 2119.80,OTHER, 779.04, 3881.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16305,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16306,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2176.58,,OUTPAT REV HCPCS COMBO 1, 2539.54,OTHER, 779.04, 4724.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16307,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16308,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2038.50,,OUTPAT REV HCPCS COMBO 1, 2390.20,OTHER, 779.04, 4424.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16309,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16310,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16311,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16312,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16313,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 188.54,,OUTPAT REV HCPCS COMBO 1, 236.81,OTHER, 138.19, 409.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16314,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16315,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 148.83,,OUTPAT REV HCPCS COMBO 1, 193.87,OTHER, 138.19, 323.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16316,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16317,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1103.60,,OUTPAT REV HCPCS COMBO 1, 1261.16,OTHER, 283.82, 2395.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16318,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1103.60,,OUTPAT REV HCPCS COMBO 1, 1261.16,OTHER, 283.82, 2395.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16319,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16320,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16321,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1066.26,,OUTPAT REV HCPCS COMBO 1, 1256.10,OTHER, 432.18, 2314.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16322,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16323,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 720.37,,OUTPAT REV HCPCS COMBO 1, 894.65,OTHER, 485.27, 1563.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16324,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16325,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1507.52,,OUTPAT REV HCPCS COMBO 1, 1751.53,OTHER, 508.57, 3272.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16326,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16327,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2259.62,,OUTPAT REV HCPCS COMBO 1, 2629.35,OTHER, 779.04, 4904.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16328,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16329,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16330,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16331,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16332,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16333,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16334,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16335,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 132.80,,OUTPAT REV HCPCS COMBO 1, 164.19,OTHER, 86.34, 288.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16336,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16337,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 188.43,,OUTPAT REV HCPCS COMBO 1, 224.35,OTHER, 86.34, 408.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16338,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16339,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 173.97,,OUTPAT REV HCPCS COMBO 1, 208.71,OTHER, 86.34, 377.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16340,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 173.97,,OUTPAT REV HCPCS COMBO 1, 208.71,OTHER, 86.34, 377.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16341,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 180.44,,OUTPAT REV HCPCS COMBO 1, 215.71,OTHER, 86.34, 391.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16342,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16343,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16344,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16345,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 118.86,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16346,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 118.86,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16347,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 118.86,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16348,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16349,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16350,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16351,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 143.58,,OUTPAT REV HCPCS COMBO 1, 175.84,OTHER, 86.34, 311.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16352,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 137.31,,OUTPAT REV HCPCS COMBO 1, 169.06,OTHER, 86.34, 298.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16353,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 137.31,,OUTPAT REV HCPCS COMBO 1, 169.06,OTHER, 86.34, 298.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16354,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16355,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16356,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16357,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 186.92,,OUTPAT REV HCPCS COMBO 1, 235.06,OTHER, 138.19, 405.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16358,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 186.92,,OUTPAT REV HCPCS COMBO 1, 235.06,OTHER, 138.19, 405.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16359,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 191.82,,OUTPAT REV HCPCS COMBO 1, 240.36,OTHER, 138.19, 416.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16360,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16361,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16362,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16363,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 184.13,,OUTPAT REV HCPCS COMBO 1, 219.70,OTHER, 86.34, 399.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16364,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 179.28,,OUTPAT REV HCPCS COMBO 1, 214.45,OTHER, 86.34, 389.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16365,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 179.28,,OUTPAT REV HCPCS COMBO 1, 214.45,OTHER, 86.34, 389.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16366,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16367,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16368,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16369,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 171.98,,OUTPAT REV HCPCS COMBO 1, 206.56,OTHER, 86.34, 373.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16370,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 176.83,,OUTPAT REV HCPCS COMBO 1, 211.81,OTHER, 86.34, 383.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16371,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 171.98,,OUTPAT REV HCPCS COMBO 1, 206.56,OTHER, 86.34, 373.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16372,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16373,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16374,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16375,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 193.69,,OUTPAT REV HCPCS COMBO 1, 230.04,OTHER, 86.34, 420.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16376,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 187.64,,OUTPAT REV HCPCS COMBO 1, 223.50,OTHER, 86.34, 407.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16377,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16378,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16379,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16380,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 194.42,,OUTPAT REV HCPCS COMBO 1, 230.83,OTHER, 86.34, 421.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16381,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 194.42,,OUTPAT REV HCPCS COMBO 1, 230.83,OTHER, 86.34, 421.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16382,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 200.47,,OUTPAT REV HCPCS COMBO 1, 237.37,OTHER, 86.34, 435.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16383,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16384,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16385,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16386,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 61.86,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16387,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 85.79,,OUTPAT REV HCPCS COMBO 1, 125.68,OTHER, 81.70, 186.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16388,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 61.86,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16389,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16390,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16391,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16392,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 178.61,,OUTPAT REV HCPCS COMBO 1, 213.73,OTHER, 86.34, 387.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16393,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 173.06,,OUTPAT REV HCPCS COMBO 1, 207.73,OTHER, 86.34, 375.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16394,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 173.07,,OUTPAT REV HCPCS COMBO 1, 207.74,OTHER, 86.34, 375.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16395,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16396,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16397,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16398,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 201.22,,OUTPAT REV HCPCS COMBO 1, 238.18,OTHER, 86.34, 436.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16399,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 206.08,,OUTPAT REV HCPCS COMBO 1, 243.44,OTHER, 86.34, 447.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16400,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 201.22,,OUTPAT REV HCPCS COMBO 1, 238.18,OTHER, 86.34, 436.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16401,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16402,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16403,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16404,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 190.08,,OUTPAT REV HCPCS COMBO 1, 238.48,OTHER, 138.19, 412.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16405,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 184.03,,OUTPAT REV HCPCS COMBO 1, 231.94,OTHER, 138.19, 399.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16406,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 184.03,,OUTPAT REV HCPCS COMBO 1, 231.94,OTHER, 138.19, 399.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16407,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16408,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16409,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16410,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 184.74,,OUTPAT REV HCPCS COMBO 1, 220.36,OTHER, 86.34, 400.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16411,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 184.79,,OUTPAT REV HCPCS COMBO 1, 220.42,OTHER, 86.34, 401.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16412,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 189.65,,OUTPAT REV HCPCS COMBO 1, 225.67,OTHER, 86.34, 411.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16413,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16414,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16415,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16416,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 153.92,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16417,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 142.52,,OUTPAT REV HCPCS COMBO 1, 174.69,OTHER, 86.34, 309.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16418,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 137.66,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16419,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 137.66,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16420,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 137.66,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16421,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 137.66,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16422,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 137.66,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16423,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 137.66,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16424,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 137.66,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16425,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 137.66,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16426,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 137.66,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16427,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 137.66,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16428,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 137.66,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16429,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16430,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16431,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16432,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16433,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16434,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16435,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16436,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16437,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16438,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16439,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16440,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16441,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16442,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 854.09,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16443,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 918.59,,OUTPAT REV HCPCS COMBO 1, 1061.06,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16444,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 918.59,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16445,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 918.59,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16446,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 918.59,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16447,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 918.59,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16448,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 918.59,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16449,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 302.05,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16450,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 302.05,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16451,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 918.59,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16452,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 918.59,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16453,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 302.05,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16454,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 918.59,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16455,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 918.59,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16456,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 854.09,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16457,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16458,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16459,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16460,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16461,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16462,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16463,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16464,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16465,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16466,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16467,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16468,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16469,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16470,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16471,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1277.29,,OUTPAT REV HCPCS COMBO 1, 1484.34,OTHER, 432.18, 2772.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16472,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1277.29,,OUTPAT REV HCPCS COMBO 1, 1484.34,OTHER, 432.18, 2772.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16473,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16474,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16475,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16476,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 609.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16477,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 609.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16478,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16479,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16480,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 864.01,,OUTPAT REV HCPCS COMBO 1, 1055.55,OTHER, 508.57, 1875.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16481,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16482,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1490.06,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16483,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1490.06,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16484,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1490.06,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16485,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16486,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16487,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16488,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16489,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16490,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16491,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16492,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16493,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16494,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16495,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16496,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16497,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16498,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16499,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16500,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16501,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16502,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16503,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16504,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16505,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16506,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16507,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16508,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16509,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16510,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16511,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16512,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16513,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16514,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16515,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16516,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16517,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16518,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16519,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16520,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1169.50,,OUTPAT REV HCPCS COMBO 1, 1450.34,OTHER, 779.04, 2538.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16521,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1169.50,,OUTPAT REV HCPCS COMBO 1, 1450.34,OTHER, 779.04, 2538.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16522,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16523,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16524,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16525,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16526,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16527,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16528,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 162.67,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16529,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 162.67,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16530,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 162.67,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16531,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16532,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16533,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16534,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.11,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16535,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.11,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16536,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.11,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16537,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.11,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16538,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.11,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16539,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16540,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16541,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16542,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16543,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 205.51,,OUTPAT REV HCPCS COMBO 1, 234.40,OTHER, 146.51, 446.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16544,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 163.43,,OUTPAT REV HCPCS COMBO 1, 234.40,OTHER, 146.51, 446.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16545,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16546,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16547,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 168.20,,OUTPAT REV HCPCS COMBO 1, 202.98,OTHER, 88.46, 365.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16548,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 168.20,,OUTPAT REV HCPCS COMBO 1, 202.98,OTHER, 88.46, 365.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16549,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 173.06,,OUTPAT REV HCPCS COMBO 1, 208.23,OTHER, 88.46, 375.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16550,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16551,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16552,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16553,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 175.83,,OUTPAT REV HCPCS COMBO 1, 210.73,OTHER, 86.34, 381.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16554,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 170.29,,OUTPAT REV HCPCS COMBO 1, 204.73,OTHER, 86.34, 369.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16555,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 170.29,,OUTPAT REV HCPCS COMBO 1, 204.73,OTHER, 86.34, 369.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16556,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16557,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16558,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16559,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 218.45,,OUTPAT REV HCPCS COMBO 1, 269.16,OTHER, 138.19, 474.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16560,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 223.30,,OUTPAT REV HCPCS COMBO 1, 274.41,OTHER, 138.19, 484.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16561,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 218.45,,OUTPAT REV HCPCS COMBO 1, 269.16,OTHER, 138.19, 474.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16562,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16563,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16564,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16565,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 341.33,,OUTPAT REV HCPCS COMBO 1, 402.07,OTHER, 138.19, 740.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16566,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 335.13,,OUTPAT REV HCPCS COMBO 1, 395.36,OTHER, 138.19, 727.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16567,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 335.13,,OUTPAT REV HCPCS COMBO 1, 395.36,OTHER, 138.19, 727.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16568,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16569,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16570,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16571,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 122.80,,OUTPAT REV HCPCS COMBO 1, 153.37,OTHER, 86.34, 266.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16572,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16573,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 205.74,,OUTPAT REV HCPCS COMBO 1, 243.07,OTHER, 86.34, 446.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16574,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 200.89,,OUTPAT REV HCPCS COMBO 1, 237.82,OTHER, 86.34, 436.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16575,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 200.89,,OUTPAT REV HCPCS COMBO 1, 237.82,OTHER, 86.34, 436.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16576,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16577,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16578,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16579,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.83,,OUTPAT REV HCPCS COMBO 1, 74.90,OTHER, 36.98, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16580,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.83,,OUTPAT REV HCPCS COMBO 1, 74.90,OTHER, 36.98, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16581,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 77.66,,OUTPAT REV HCPCS COMBO 1, 116.89,OTHER, 73.96, 168.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16582,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16583,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16584,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16585,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 172.02,,OUTPAT REV HCPCS COMBO 1, 218.95,OTHER, 138.19, 373.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16586,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 172.02,,OUTPAT REV HCPCS COMBO 1, 218.95,OTHER, 138.19, 373.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16587,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 177.89,,OUTPAT REV HCPCS COMBO 1, 225.30,OTHER, 138.19, 386.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16588,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16589,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16590,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16591,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 194.60,,OUTPAT REV HCPCS COMBO 1, 243.37,OTHER, 138.19, 422.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16592,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 188.49,,OUTPAT REV HCPCS COMBO 1, 236.76,OTHER, 138.19, 409.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16593,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 188.49,,OUTPAT REV HCPCS COMBO 1, 236.76,OTHER, 138.19, 409.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16594,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16595,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16596,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16597,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 153.49,,OUTPAT REV HCPCS COMBO 1, 186.56,OTHER, 86.34, 333.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16598,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 153.49,,OUTPAT REV HCPCS COMBO 1, 186.56,OTHER, 86.34, 333.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16599,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16600,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16601,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 212.32,,OUTPAT REV HCPCS COMBO 1, 250.19,OTHER, 86.34, 460.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16602,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 207.38,,OUTPAT REV HCPCS COMBO 1, 244.84,OTHER, 86.34, 450.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16603,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 207.47,,OUTPAT REV HCPCS COMBO 1, 244.94,OTHER, 86.34, 450.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16604,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16605,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16606,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16607,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 105.20,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16608,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 105.20,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16609,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 105.20,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16610,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16611,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16612,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16613,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16614,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16615,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16616,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16617,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16618,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16619,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16620,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16621,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 146.74,,OUTPAT REV HCPCS COMBO 1, 179.26,OTHER, 86.34, 318.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16622,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16623,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16624,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16625,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16626,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16627,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16628,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16629,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16630,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16631,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16632,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16633,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16634,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16635,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16636,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16637,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16638,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1040.71,,OUTPAT REV HCPCS COMBO 1, 1193.14,OTHER, 283.82, 2258.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16639,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16640,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16641,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16642,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16643,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16644,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16645,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16646,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16647,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16648,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16649,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16650,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16651,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16652,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16653,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16654,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16655,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16656,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16657,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16658,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16659,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16660,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16661,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16662,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16663,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1231.69,,OUTPAT REV HCPCS COMBO 1, 1435.02,OTHER, 432.18, 2673.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16664,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1225.57,,OUTPAT REV HCPCS COMBO 1, 1428.39,OTHER, 432.18, 2660.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16665,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1225.57,,OUTPAT REV HCPCS COMBO 1, 1428.39,OTHER, 432.18, 2660.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16666,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16667,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16668,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16669,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 609.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16670,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 609.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16671,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 609.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16672,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16673,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16674,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16675,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 627.13,,OUTPAT REV HCPCS COMBO 1, 796.22,OTHER, 495.38, 1361.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16676,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 627.13,,OUTPAT REV HCPCS COMBO 1, 796.22,OTHER, 495.38, 1361.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16677,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16678,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16679,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1335.96,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16680,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1335.96,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16681,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1335.96,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16682,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1335.96,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16683,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1335.96,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16684,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1335.96,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16685,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16686,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16687,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16688,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16689,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16690,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16691,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1634.60,,OUTPAT REV HCPCS COMBO 1, 1953.37,OTHER, 779.04, 3547.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16692,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1634.60,,OUTPAT REV HCPCS COMBO 1, 1953.37,OTHER, 779.04, 3547.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16693,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16694,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16695,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16696,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16697,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16698,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16699,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16700,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16701,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16702,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16703,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16704,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16705,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16706,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16707,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16708,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16709,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16710,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16711,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16712,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16713,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16714,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16715,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2078.21,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16716,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2078.21,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16717,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2078.21,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16718,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2078.21,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16719,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2078.21,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16720,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16721,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16722,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16723,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16724,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16725,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1227.35,OTHER, 786.90, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16726,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1038.45,,OUTPAT REV HCPCS COMBO 1, 1323.48,OTHER, 786.90, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16727,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1038.45,,OUTPAT REV HCPCS COMBO 1, 1474.10,OTHER, 989.00, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16728,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 826.25,,OUTPAT REV HCPCS COMBO 1, 1227.35,OTHER, 786.90, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16729,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 826.25,,OUTPAT REV HCPCS COMBO 1, 1323.48,OTHER, 786.90, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16730,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16731,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16732,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16733,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16734,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16735,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 74.95,,OUTPAT REV HCPCS COMBO 1, 102.58,OTHER, 71.38, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16736,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 74.95,,OUTPAT REV HCPCS COMBO 1, 102.58,OTHER, 71.38, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16737,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16738,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16739,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.83,,OUTPAT REV HCPCS COMBO 1, 83.13,OTHER, 36.98, 172.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16740,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16741,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 267.70,,OUTPAT REV HCPCS COMBO 1, 322.43,OTHER, 138.19, 581.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16742,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 267.70,,OUTPAT REV HCPCS COMBO 1, 322.43,OTHER, 138.19, 581.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16743,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16744,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16745,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1182.07,,OUTPAT REV HCPCS COMBO 1, 1346.03,OTHER, 283.82, 2565.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16746,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16747,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1332.66,,OUTPAT REV HCPCS COMBO 1, 1544.22,OTHER, 432.18, 2892.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16748,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16749,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1504.95,,OUTPAT REV HCPCS COMBO 1, 1743.20,OTHER, 485.27, 3266.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16750,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16751,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2699.98,,OUTPAT REV HCPCS COMBO 1, 3113.75,OTHER, 813.20, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16752,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16753,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1502.96,,OUTPAT REV HCPCS COMBO 1, 1743.46,OTHER, 495.38, 3262.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16754,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16755,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2351.96,,OUTPAT REV HCPCS COMBO 1, 2609.45,OTHER, 276.02, 5105.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16756,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2351.96,,OUTPAT REV HCPCS COMBO 1, 2609.45,OTHER, 276.02, 5105.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16757,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16758,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16759,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2699.98,,OUTPAT REV HCPCS COMBO 1, 3021.78,OTHER, 426.91, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16760,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2699.98,,OUTPAT REV HCPCS COMBO 1, 3021.78,OTHER, 426.91, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16761,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16762,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16763,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 3025.14,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16764,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 3025.14,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16765,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 3025.14,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16766,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16767,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16768,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16769,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1450.33,,OUTPAT REV HCPCS COMBO 1, 1689.68,OTHER, 508.57, 3148.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16770,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1450.33,,OUTPAT REV HCPCS COMBO 1, 1689.68,OTHER, 508.57, 3148.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16771,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16772,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16773,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1527.06,,OUTPAT REV HCPCS COMBO 1, 1837.06,OTHER, 779.04, 3314.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16774,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16775,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1128.75,,OUTPAT REV HCPCS COMBO 1, 2098.35,OTHER, 1075.00, 3967.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16776,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1827.67,,OUTPAT REV HCPCS COMBO 1, 2098.35,OTHER, 1075.00, 3967.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16777,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16778,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16779,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16780,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 315.15,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16781,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 315.15,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16782,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 315.15,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16783,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16784,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16785,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 495.99,,OUTPAT REV HCPCS COMBO 1, 704.06,OTHER, 472.37, 1076.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16786,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16787,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 174.46,,OUTPAT REV HCPCS COMBO 1, 248.14,OTHER, 166.15, 378.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16788,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16789,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 342.50,,OUTPAT REV HCPCS COMBO 1, 429.88,OTHER, 249.71, 743.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16790,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16791,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1273.76,,OUTPAT REV HCPCS COMBO 1, 1495.57,OTHER, 495.38, 2764.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16792,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1273.76,,OUTPAT REV HCPCS COMBO 1, 1495.57,OTHER, 495.38, 2764.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16793,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16794,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16795,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 158.03,,OUTPAT REV HCPCS COMBO 1, 224.32,OTHER, 150.50, 343.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16796,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16797,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 325.30,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16798,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 325.30,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16799,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 325.30,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16800,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16801,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16802,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16803,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 244.97,,OUTPAT REV HCPCS COMBO 1, 286.59,OTHER, 90.89, 531.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16804,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16805,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 230.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16806,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 230.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16807,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 230.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16808,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 237.04,,OUTPAT REV HCPCS COMBO 1, 288.12,OTHER, 133.37, 514.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16809,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16810,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16811,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16812,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16813,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 434.37,,OUTPAT REV HCPCS COMBO 1, 503.49,OTHER, 141.55, 942.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16814,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16815,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 396.69,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16816,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 396.69,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16817,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 396.69,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16818,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 396.69,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16819,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 396.69,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16820,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16821,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16822,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16823,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16824,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16825,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 396.69,,OUTPAT REV HCPCS COMBO 1, 468.07,OTHER, 163.97, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16826,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16827,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 357.77,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16828,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 357.77,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16829,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 357.77,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16830,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 357.77,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16831,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 352.09,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16832,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16833,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16834,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16835,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16836,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16837,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 352.09,,OUTPAT REV HCPCS COMBO 1, 414.50,OTHER, 141.55, 764.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16838,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16839,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 169.31,,OUTPAT REV HCPCS COMBO 1, 214.87,OTHER, 133.37, 367.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16840,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16841,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 346.76,,OUTPAT REV HCPCS COMBO 1, 408.73,OTHER, 141.55, 752.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16842,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16843,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 438.13,,OUTPAT REV HCPCS COMBO 1, 507.55,OTHER, 141.55, 950.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16844,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16845,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 697.12,,OUTPAT REV HCPCS COMBO 1, 775.60,OTHER, 90.89, 1513.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16846,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16847,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 239.30,,OUTPAT REV HCPCS COMBO 1, 290.56,OTHER, 133.37, 519.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16848,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16849,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 356.96,,OUTPAT REV HCPCS COMBO 1, 419.77,OTHER, 141.55, 774.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16850,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16851,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 404.87,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16852,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 404.87,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16853,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 404.87,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16854,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16855,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16856,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16857,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 282.53,,OUTPAT REV HCPCS COMBO 1, 322.12,OTHER, 90.89, 613.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16858,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 273.12,,OUTPAT REV HCPCS COMBO 1, 322.12,OTHER, 90.89, 613.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16859,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16860,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16861,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 346.52,,OUTPAT REV HCPCS COMBO 1, 408.48,OTHER, 141.55, 752.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16862,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16863,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 722.40,,OUTPAT REV HCPCS COMBO 1, 813.95,OTHER, 137.10, 1568.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16864,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 456.76,,OUTPAT REV HCPCS COMBO 1, 526.64,OTHER, 137.10, 991.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16865,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 456.76,,OUTPAT REV HCPCS COMBO 1, 526.64,OTHER, 137.10, 991.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16866,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16867,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16868,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16869,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 162.07,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16870,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 248.33,,OUTPAT REV HCPCS COMBO 1, 300.33,OTHER, 133.37, 539.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16871,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 162.07,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16872,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 162.07,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16873,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 162.07,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16874,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 162.07,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16875,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 162.07,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16876,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 162.07,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16877,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 162.07,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16878,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16879,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16880,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16881,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16882,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16883,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16884,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16885,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16886,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16887,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 300.20,,OUTPAT REV HCPCS COMBO 1, 426.14,OTHER, 285.90, 651.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16888,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16889,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 191.70,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16890,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 191.70,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16891,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 191.70,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16892,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16893,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16894,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16895,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16896,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 131.39,,OUTPAT REV HCPCS COMBO 1, 186.51,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16897,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 131.39,,OUTPAT REV HCPCS COMBO 1, 186.51,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16898,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 64.11,,OUTPAT REV HCPCS COMBO 1, 91.01,OTHER, 61.06, 139.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16899,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 22.20,,OUTPAT REV HCPCS COMBO 1, 78.82,OTHER, 21.15, 181.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16900,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 131.39,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16901,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 131.39,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16902,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 131.39,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16903,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 131.39,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16904,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16905,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16906,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16907,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16908,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 221.24,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16909,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 184.66,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16910,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 221.24,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16911,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16912,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16913,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 85.51,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16914,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 85.51,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16915,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 85.51,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16916,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 85.51,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16917,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 85.51,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16918,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 85.51,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16919,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 85.51,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16920,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16921,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16922,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16923,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16924,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16925,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16926,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16927,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 77.21,,OUTPAT REV HCPCS COMBO 1, 116.40,OTHER, 73.53, 167.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16928,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16929,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 331.78,,OUTPAT REV HCPCS COMBO 1, 414.07,OTHER, 232.03, 720.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16930,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 88.49,,OUTPAT REV HCPCS COMBO 1, 158.67,OTHER, 84.28, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16931,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 158.48,,OUTPAT REV HCPCS COMBO 1, 158.67,OTHER, 84.28, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16932,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16933,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16934,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 133.64,,OUTPAT REV HCPCS COMBO 1, 154.63,OTHER, 42.36, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16935,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 158.48,,OUTPAT REV HCPCS COMBO 1, 204.30,OTHER, 138.19, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16936,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16937,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 576.49,,OUTPAT REV HCPCS COMBO 1, 660.83,OTHER, 156.82, 1251.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16938,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 576.49,,OUTPAT REV HCPCS COMBO 1, 660.83,OTHER, 156.82, 1251.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16939,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16940,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16941,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 448.14,,OUTPAT REV HCPCS COMBO 1, 533.81,OTHER, 206.35, 972.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16942,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 448.14,,OUTPAT REV HCPCS COMBO 1, 533.81,OTHER, 206.35, 972.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16943,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16944,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16945,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 630.25,,OUTPAT REV HCPCS COMBO 1, 757.92,OTHER, 320.35, 1367.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16946,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16947,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 760.95,,OUTPAT REV HCPCS COMBO 1, 899.81,OTHER, 322.62, 1651.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16948,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16949,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 889.46,,OUTPAT REV HCPCS COMBO 1, 1092.65,OTHER, 548.80, 1930.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16950,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16951,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 705.75,,OUTPAT REV HCPCS COMBO 1, 864.03,OTHER, 423.08, 1531.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16952,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16953,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 225.75,,OUTPAT REV HCPCS COMBO 1, 344.89,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16954,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16955,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 677.25,,OUTPAT REV HCPCS COMBO 1, 830.31,OTHER, 410.92, 1470.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16956,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16957,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 930.09,,OUTPAT REV HCPCS COMBO 1, 1103.77,OTHER, 410.92, 2018.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16958,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16959,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 948.15,,OUTPAT REV HCPCS COMBO 1, 1111.16,OTHER, 359.95, 2058.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16960,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16961,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 497.78,,OUTPAT REV HCPCS COMBO 1, 624.07,OTHER, 359.95, 1080.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16962,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16963,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 542.40,,OUTPAT REV HCPCS COMBO 1, 672.34,OTHER, 360.01, 1177.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16964,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16965,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 437.96,,OUTPAT REV HCPCS COMBO 1, 559.38,OTHER, 360.01, 950.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16966,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16967,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1056.22,,OUTPAT REV HCPCS COMBO 1, 1228.06,OTHER, 360.01, 2292.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16968,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16969,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1117.24,,OUTPAT REV HCPCS COMBO 1, 1294.05,OTHER, 360.01, 2425.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16970,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16971,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 494.39,,OUTPAT REV HCPCS COMBO 1, 701.80,OTHER, 470.85, 1073.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16972,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16973,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 814.28,,OUTPAT REV HCPCS COMBO 1, 1149.19,OTHER, 775.51, 1767.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16974,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 814.28,,OUTPAT REV HCPCS COMBO 1, 1149.19,OTHER, 775.51, 1767.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16975,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16976,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16977,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1848.57,,OUTPAT REV HCPCS COMBO 1, 2267.81,OTHER, 1127.76, 4012.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16978,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16979,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 655.62,,OUTPAT REV HCPCS COMBO 1, 815.01,OTHER, 444.92, 1423.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16980,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 655.62,,OUTPAT REV HCPCS COMBO 1, 815.01,OTHER, 444.92, 1423.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16981,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16982,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16983,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 525.43,,OUTPAT REV HCPCS COMBO 1, 635.79,OTHER, 283.54, 1140.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16984,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16985,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 843.78,,OUTPAT REV HCPCS COMBO 1, 984.09,OTHER, 300.36, 1831.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16986,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16987,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 873.35,,OUTPAT REV HCPCS COMBO 1, 1050.06,OTHER, 443.12, 1895.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16988,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16989,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 469.56,,OUTPAT REV HCPCS COMBO 1, 684.67,OTHER, 447.20, 1019.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16990,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16991,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2150.95,,OUTPAT REV HCPCS COMBO 1, 2685.69,OTHER, 1509.32, 4668.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16992,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16993,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2227.70,,OUTPAT REV HCPCS COMBO 1, 2768.70,OTHER, 1509.32, 4835.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16994,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 16995,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 27.36,,OUTPAT REV HCPCS COMBO 1, 34.30,OTHER, 19.78, 59.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16996,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 27.36,,OUTPAT REV HCPCS COMBO 1, 32.49,OTHER, 12.18, 59.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16997,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 280.83,,OUTPAT REV HCPCS COMBO 1, 398.65,OTHER, 267.46, 609.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16998,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 63.14,,OUTPAT REV HCPCS COMBO 1, 70.69,OTHER, 10.09, 137.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 16999,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 109.60,,OUTPAT REV HCPCS COMBO 1, 122.16,OTHER, 15.20, 237.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17000,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 86.00,,OUTPAT REV HCPCS COMBO 1, 97.60,OTHER, 19.28, 186.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17001,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 86.00,,OUTPAT REV HCPCS COMBO 1, 97.60,OTHER, 19.28, 186.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17002,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 74.50,,OUTPAT REV HCPCS COMBO 1, 83.55,OTHER, 12.50, 161.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17003,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 74.50,,OUTPAT REV HCPCS COMBO 1, 83.55,OTHER, 12.50, 161.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17004,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 129.00,,OUTPAT REV HCPCS COMBO 1, 155.85,OTHER, 68.59, 280.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17005,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 70.44,,OUTPAT REV HCPCS COMBO 1, 78.98,OTHER, 11.76, 152.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17006,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 59.15,,OUTPAT REV HCPCS COMBO 1, 69.30,OTHER, 22.37, 128.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17007,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 201.82,,OUTPAT REV HCPCS COMBO 1, 229.30,OTHER, 46.28, 438.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17008,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 79.58,,OUTPAT REV HCPCS COMBO 1, 88.95,OTHER, 20.98, 172.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17009,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 75.67,,OUTPAT REV HCPCS COMBO 1, 88.95,OTHER, 20.98, 172.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17010,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 53.39,OTHER, 19.13, 98.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17011,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 53.39,OTHER, 19.13, 98.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17012,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.83,,OUTPAT REV HCPCS COMBO 1, 80.17,OTHER, 19.50, 151.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17013,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 43.62,,OUTPAT REV HCPCS COMBO 1, 54.61,OTHER, 31.20, 94.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17014,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.79,,OUTPAT REV HCPCS COMBO 1, 80.03,OTHER, 19.08, 151.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17015,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.00,,OUTPAT REV HCPCS COMBO 1, 79.17,OTHER, 19.08, 149.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17016,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 57.03,,OUTPAT REV HCPCS COMBO 1, 63.95,OTHER, 9.52, 123.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17017,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 21.22,,OUTPAT REV HCPCS COMBO 1, 28.28,OTHER, 20.21, 46.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17018,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 73.18,,OUTPAT REV HCPCS COMBO 1, 83.69,OTHER, 19.08, 158.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17019,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 44.59,,OUTPAT REV HCPCS COMBO 1, 53.47,OTHER, 22.03, 96.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17020,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.59,,OUTPAT REV HCPCS COMBO 1, 79.81,OTHER, 19.08, 151.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17021,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 36.92,,OUTPAT REV HCPCS COMBO 1, 44.64,OTHER, 19.78, 80.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17022,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 130.56,,OUTPAT REV HCPCS COMBO 1, 145.91,OTHER, 19.78, 283.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17023,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 55.40,,OUTPAT REV HCPCS COMBO 1, 64.76,OTHER, 20.36, 120.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17024,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 108.41,,OUTPAT REV HCPCS COMBO 1, 121.34,OTHER, 17.16, 235.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17025,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 74.07,,OUTPAT REV HCPCS COMBO 1, 84.76,OTHER, 19.50, 160.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17026,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 117.38,,OUTPAT REV HCPCS COMBO 1, 134.69,OTHER, 32.53, 254.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17027,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 78.15,,OUTPAT REV HCPCS COMBO 1, 90.91,OTHER, 26.84, 169.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17028,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 85.94,,OUTPAT REV HCPCS COMBO 1, 56.90,OTHER, 10.75, 186.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17029,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 11.29,,OUTPAT REV HCPCS COMBO 1, 56.90,OTHER, 10.75, 186.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17030,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 18.06,,OUTPAT REV HCPCS COMBO 1, 23.85,OTHER, 17.20, 39.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17031,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 18.06,,OUTPAT REV HCPCS COMBO 1, 23.85,OTHER, 17.20, 39.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17032,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 118.24,,OUTPAT REV HCPCS COMBO 1, 178.46,OTHER, 112.61, 289.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17033,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 133.19,,OUTPAT REV HCPCS COMBO 1, 178.46,OTHER, 112.61, 289.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17034,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 76.30,,OUTPAT REV HCPCS COMBO 1, 108.31,OTHER, 72.67, 165.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17035,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.73,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17036,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 34.31,,OUTPAT REV HCPCS COMBO 1, 48.71,OTHER, 32.68, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17037,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 126.77,,OUTPAT REV HCPCS COMBO 1, 179.95,OTHER, 120.73, 275.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17038,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 80.75,,OUTPAT REV HCPCS COMBO 1, 114.63,OTHER, 76.91, 175.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17039,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 18.43,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17040,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.86,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17041,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 18.43,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17042,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 18.43,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17043,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 63.66,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17044,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.81,,OUTPAT REV HCPCS COMBO 1, 67.87,OTHER, 45.53, 103.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17045,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 71.79,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17046,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 71.79,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17047,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 71.79,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17048,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 60.95,,OUTPAT REV HCPCS COMBO 1, 86.52,OTHER, 58.05, 132.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17049,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.83,,OUTPAT REV HCPCS COMBO 1, 120.81,OTHER, 36.98, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17050,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 131.39,,OUTPAT REV HCPCS COMBO 1, 120.81,OTHER, 36.98, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17051,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 31.25,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17052,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 31.25,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17053,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 31.25,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17054,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 18.64,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17055,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 18.64,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17056,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 18.64,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17057,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 5.87,,OUTPAT REV HCPCS COMBO 1, 7.12,OTHER, 3.24, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17058,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 6.77,,OUTPAT REV HCPCS COMBO 1, 8.07,OTHER, 3.12, 14.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17059,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 28.58,,OUTPAT REV HCPCS COMBO 1, 33.86,OTHER, 12.40, 62.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17060,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 28.58,,OUTPAT REV HCPCS COMBO 1, 33.86,OTHER, 12.40, 62.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17061,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.27,,OUTPAT REV HCPCS COMBO 1, 75.71,OTHER, 12.40, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17062,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.27,,OUTPAT REV HCPCS COMBO 1, 75.71,OTHER, 12.40, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17063,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 111.36,,OUTPAT REV HCPCS COMBO 1, 145.60,OTHER, 105.66, 241.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17064,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 111.36,,OUTPAT REV HCPCS COMBO 1, 145.60,OTHER, 105.66, 241.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17065,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 222.14,,OUTPAT REV HCPCS COMBO 1, 262.66,OTHER, 94.12, 482.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17066,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 367.58,,OUTPAT REV HCPCS COMBO 1, 428.98,OTHER, 131.99, 797.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17067,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 91.36,,OUTPAT REV HCPCS COMBO 1, 129.68,OTHER, 87.01, 198.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17068,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 172.47,,OUTPAT REV HCPCS COMBO 1, 244.83,OTHER, 164.26, 374.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17069,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 172.47,,OUTPAT REV HCPCS COMBO 1, 244.83,OTHER, 164.26, 374.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17070,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.71,,OUTPAT REV HCPCS COMBO 1, 53.15,OTHER, 6.50, 103.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17071,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.38,,OUTPAT REV HCPCS COMBO 1, 38.90,OTHER, 11.76, 72.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17072,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 123.52,,OUTPAT REV HCPCS COMBO 1, 146.83,OTHER, 55.61, 268.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17073,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 17.04,,OUTPAT REV HCPCS COMBO 1, 20.13,OTHER, 7.13, 37.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17074,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 17.04,,OUTPAT REV HCPCS COMBO 1, 20.13,OTHER, 7.13, 37.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17075,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 24.27,,OUTPAT REV HCPCS COMBO 1, 28.92,OTHER, 11.21, 52.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17076,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 24.27,,OUTPAT REV HCPCS COMBO 1, 28.92,OTHER, 11.21, 52.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17077,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 54.18,,OUTPAT REV HCPCS COMBO 1, 60.58,OTHER, 8.33, 117.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17078,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 54.18,,OUTPAT REV HCPCS COMBO 1, 60.58,OTHER, 8.33, 117.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17079,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 43.96,,OUTPAT REV HCPCS COMBO 1, 50.88,OTHER, 13.98, 95.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17080,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 61.44,,OUTPAT REV HCPCS COMBO 1, 71.06,OTHER, 19.36, 133.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17081,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 97.00,,OUTPAT REV HCPCS COMBO 1, 109.86,OTHER, 20.82, 210.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17082,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 68.80,,OUTPAT REV HCPCS COMBO 1, 80.16,OTHER, 24.14, 149.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17083,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 68.80,,OUTPAT REV HCPCS COMBO 1, 80.16,OTHER, 24.14, 149.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17084,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 53.73,,OUTPAT REV HCPCS COMBO 1, 63.10,OTHER, 20.98, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17085,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 53.73,,OUTPAT REV HCPCS COMBO 1, 63.10,OTHER, 20.98, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17086,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 44.91,,OUTPAT REV HCPCS COMBO 1, 50.79,OTHER, 9.34, 97.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17087,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 44.91,,OUTPAT REV HCPCS COMBO 1, 50.79,OTHER, 9.34, 97.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17088,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 83.53,,OUTPAT REV HCPCS COMBO 1, 100.38,OTHER, 42.16, 181.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17089,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 102.53,,OUTPAT REV HCPCS COMBO 1, 121.92,OTHER, 46.34, 222.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17090,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 39.73,,OUTPAT REV HCPCS COMBO 1, 50.20,OTHER, 30.37, 86.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17091,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 101.53,,OUTPAT REV HCPCS COMBO 1, 116.31,OTHER, 27.31, 220.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17092,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 42.89,,OUTPAT REV HCPCS COMBO 1, 49.78,OTHER, 14.24, 93.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17093,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 53.53,,OUTPAT REV HCPCS COMBO 1, 63.44,OTHER, 23.30, 116.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17094,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 32.03,,OUTPAT REV HCPCS COMBO 1, 36.36,OTHER, 7.22, 69.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17095,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 32.03,,OUTPAT REV HCPCS COMBO 1, 36.36,OTHER, 7.22, 69.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17096,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 28.99,,OUTPAT REV HCPCS COMBO 1, 33.07,OTHER, 7.22, 62.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17097,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 16.48,,OUTPAT REV HCPCS COMBO 1, 19.33,OTHER, 6.31, 35.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17098,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 29.42,,OUTPAT REV HCPCS COMBO 1, 33.34,OTHER, 6.38, 63.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17099,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.41,,OUTPAT REV HCPCS COMBO 1, 56.73,OTHER, 22.92, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17100,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 105.40,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17101,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 112.42,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17102,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 105.40,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17103,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 105.84,,OUTPAT REV HCPCS COMBO 1, 123.66,OTHER, 38.58, 229.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17104,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 29.88,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17105,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 29.88,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17106,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 29.88,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17107,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 59.68,,OUTPAT REV HCPCS COMBO 1, 69.24,OTHER, 19.70, 129.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17108,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 44.29,,OUTPAT REV HCPCS COMBO 1, 49.97,OTHER, 8.69, 96.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17109,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 37.02,,OUTPAT REV HCPCS COMBO 1, 44.47,OTHER, 18.58, 80.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17110,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 56.32,,OUTPAT REV HCPCS COMBO 1, 65.14,OTHER, 17.74, 122.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17111,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 74.66,,OUTPAT REV HCPCS COMBO 1, 87.25,OTHER, 27.30, 162.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17112,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 74.66,,OUTPAT REV HCPCS COMBO 1, 87.25,OTHER, 27.30, 162.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17113,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 49.21,,OUTPAT REV HCPCS COMBO 1, 59.01,OTHER, 24.29, 106.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17114,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 109.76,,OUTPAT REV HCPCS COMBO 1, 127.93,OTHER, 36.36, 240.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17115,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 110.81,,OUTPAT REV HCPCS COMBO 1, 127.93,OTHER, 36.36, 240.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17116,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 48.79,,OUTPAT REV HCPCS COMBO 1, 56.46,OTHER, 15.47, 105.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17117,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 10.84,,OUTPAT REV HCPCS COMBO 1, 13.69,OTHER, 8.28, 23.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17118,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 64.22,,OUTPAT REV HCPCS COMBO 1, 73.71,OTHER, 17.87, 139.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17119,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 75.82,,OUTPAT REV HCPCS COMBO 1, 87.73,OTHER, 24.06, 164.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17120,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 75.82,,OUTPAT REV HCPCS COMBO 1, 87.73,OTHER, 24.06, 164.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17121,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 56.14,,OUTPAT REV HCPCS COMBO 1, 66.31,OTHER, 23.47, 121.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17122,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 56.14,,OUTPAT REV HCPCS COMBO 1, 66.31,OTHER, 23.47, 121.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17123,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 168.21,,OUTPAT REV HCPCS COMBO 1, 190.19,OTHER, 34.69, 365.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17124,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 190.24,,OUTPAT REV HCPCS COMBO 1, 214.01,OTHER, 34.69, 412.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17125,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 41.85,,OUTPAT REV HCPCS COMBO 1, 47.49,OTHER, 9.37, 90.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17126,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 41.85,,OUTPAT REV HCPCS COMBO 1, 47.49,OTHER, 9.37, 90.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17127,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 34.31,,OUTPAT REV HCPCS COMBO 1, 41.70,OTHER, 19.28, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17128,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 51.56,,OUTPAT REV HCPCS COMBO 1, 59.73,OTHER, 16.63, 111.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17129,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 27.62,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17130,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 27.62,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17131,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 27.62,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17132,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 34.52,,OUTPAT REV HCPCS COMBO 1, 39.11,OTHER, 7.46, 74.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17133,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 34.52,,OUTPAT REV HCPCS COMBO 1, 39.11,OTHER, 7.46, 74.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17134,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 83.42,,OUTPAT REV HCPCS COMBO 1, 93.47,OTHER, 13.62, 181.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17135,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 83.42,,OUTPAT REV HCPCS COMBO 1, 93.47,OTHER, 13.62, 181.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17136,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 37.93,,OUTPAT REV HCPCS COMBO 1, 45.06,OTHER, 16.97, 82.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17137,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 68.42,,OUTPAT REV HCPCS COMBO 1, 76.21,OTHER, 9.31, 148.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17138,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 62.00,,OUTPAT REV HCPCS COMBO 1, 72.23,OTHER, 21.72, 134.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17139,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 62.00,,OUTPAT REV HCPCS COMBO 1, 72.23,OTHER, 21.72, 134.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17140,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 63.81,,OUTPAT REV HCPCS COMBO 1, 75.36,OTHER, 26.66, 138.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17141,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 63.81,,OUTPAT REV HCPCS COMBO 1, 75.36,OTHER, 26.66, 138.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17142,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 109.80,,OUTPAT REV HCPCS COMBO 1, 127.42,OTHER, 36.38, 238.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17143,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 109.80,,OUTPAT REV HCPCS COMBO 1, 127.42,OTHER, 36.38, 238.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17144,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 80.84,,OUTPAT REV HCPCS COMBO 1, 93.87,OTHER, 27.06, 175.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17145,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 116.41,,OUTPAT REV HCPCS COMBO 1, 135.49,OTHER, 40.24, 252.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17146,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 116.41,,OUTPAT REV HCPCS COMBO 1, 135.49,OTHER, 40.24, 252.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17147,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.27,,OUTPAT REV HCPCS COMBO 1, 83.83,OTHER, 46.51, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17148,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 60.50,,OUTPAT REV HCPCS COMBO 1, 73.72,OTHER, 34.82, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17149,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 61.86,,OUTPAT REV HCPCS COMBO 1, 75.45,OTHER, 35.93, 134.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17150,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 105.09,,OUTPAT REV HCPCS COMBO 1, 121.64,OTHER, 33.53, 228.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17151,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 62.33,,OUTPAT REV HCPCS COMBO 1, 69.17,OTHER, 7.34, 135.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17152,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 109.94,,OUTPAT REV HCPCS COMBO 1, 124.67,OTHER, 24.19, 238.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17153,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 66.37,,OUTPAT REV HCPCS COMBO 1, 76.46,OTHER, 19.63, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17154,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 61.43,,OUTPAT REV HCPCS COMBO 1, 71.48,OTHER, 21.17, 133.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17155,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 191.33,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17156,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.99,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17157,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.75,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17158,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.75,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17159,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.75,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17160,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 54.84,,OUTPAT REV HCPCS COMBO 1, 64.96,OTHER, 23.70, 119.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17161,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 29.80,,OUTPAT REV HCPCS COMBO 1, 34.98,OTHER, 11.54, 64.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17162,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 179.91,,OUTPAT REV HCPCS COMBO 1, 203.52,OTHER, 37.54, 390.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17163,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 51.47,,OUTPAT REV HCPCS COMBO 1, 61.71,OTHER, 25.39, 111.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17164,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 22.46,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17165,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 22.46,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17166,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 22.46,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17167,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 24.94,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17168,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 24.94,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17169,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 24.94,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17170,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 11.83,,OUTPAT REV HCPCS COMBO 1, 14.14,OTHER, 5.66, 25.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17171,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 58.09,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 6.84, 126.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17172,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 58.09,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 6.84, 126.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17173,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 50.47,,OUTPAT REV HCPCS COMBO 1, 57.91,OTHER, 13.97, 109.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17174,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 32.43,,OUTPAT REV HCPCS COMBO 1, 37.55,OTHER, 10.37, 70.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17175,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 81.70,,OUTPAT REV HCPCS COMBO 1, 94.73,OTHER, 26.76, 177.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17176,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 81.70,,OUTPAT REV HCPCS COMBO 1, 94.73,OTHER, 26.76, 177.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17177,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 81.52,,OUTPAT REV HCPCS COMBO 1, 94.52,OTHER, 26.66, 176.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17178,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 81.52,,OUTPAT REV HCPCS COMBO 1, 94.52,OTHER, 26.66, 176.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17179,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 58.00,,OUTPAT REV HCPCS COMBO 1, 67.05,OTHER, 18.12, 125.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17180,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 62.31,,OUTPAT REV HCPCS COMBO 1, 74.92,OTHER, 31.62, 135.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17181,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 41.58,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17182,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 41.58,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17183,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 41.58,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17184,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 86.62,,OUTPAT REV HCPCS COMBO 1, 99.83,OTHER, 25.80, 188.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17185,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 135.90,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17186,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 119.82,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17187,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 119.82,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17188,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 119.82,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17189,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 119.82,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17190,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 119.82,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17191,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 133.92,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17192,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 80.85,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17193,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 124.65,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17194,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 19.41,,OUTPAT REV HCPCS COMBO 1, 25.93,OTHER, 18.49, 42.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17195,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 60.21,,OUTPAT REV HCPCS COMBO 1, 69.04,OTHER, 16.46, 130.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17196,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.52,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17197,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.52,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17198,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.52,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17199,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.14,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17200,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.14,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17201,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.14,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17202,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.14,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17203,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 61.09,,OUTPAT REV HCPCS COMBO 1, 70.04,OTHER, 16.66, 132.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17204,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 39.04,,OUTPAT REV HCPCS COMBO 1, 51.00,OTHER, 8.70, 111.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17205,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 51.43,,OUTPAT REV HCPCS COMBO 1, 51.00,OTHER, 8.70, 111.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17206,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 74.95,,OUTPAT REV HCPCS COMBO 1, 85.45,OTHER, 18.42, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17207,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 57.34,,OUTPAT REV HCPCS COMBO 1, 68.77,OTHER, 28.37, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17208,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 46.80,,OUTPAT REV HCPCS COMBO 1, 54.77,OTHER, 17.44, 101.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17209,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 46.80,,OUTPAT REV HCPCS COMBO 1, 54.77,OTHER, 17.44, 101.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17210,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 53.73,,OUTPAT REV HCPCS COMBO 1, 60.48,OTHER, 9.92, 116.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17211,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 53.73,,OUTPAT REV HCPCS COMBO 1, 60.48,OTHER, 9.92, 116.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17212,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 123.13,,OUTPAT REV HCPCS COMBO 1, 149.05,OTHER, 66.68, 267.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17213,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 29.35,,OUTPAT REV HCPCS COMBO 1, 43.46,OTHER, 27.95, 63.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17214,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 36.44,,OUTPAT REV HCPCS COMBO 1, 43.01,OTHER, 15.12, 79.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17215,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 36.44,,OUTPAT REV HCPCS COMBO 1, 43.01,OTHER, 15.12, 79.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17216,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 35.45,,OUTPAT REV HCPCS COMBO 1, 40.64,OTHER, 9.65, 76.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17217,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 181.01,,OUTPAT REV HCPCS COMBO 1, 204.04,OTHER, 34.72, 392.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17218,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 48.00,,OUTPAT REV HCPCS COMBO 1, 57.49,OTHER, 23.41, 104.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17219,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 142.16,,OUTPAT REV HCPCS COMBO 1, 159.56,OTHER, 24.40, 308.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17220,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 142.16,,OUTPAT REV HCPCS COMBO 1, 159.56,OTHER, 24.40, 308.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17221,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 75.25,,OUTPAT REV HCPCS COMBO 1, 74.79,OTHER, 18.60, 163.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17222,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 54.87,,OUTPAT REV HCPCS COMBO 1, 74.79,OTHER, 18.60, 163.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17223,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 98.88,,OUTPAT REV HCPCS COMBO 1, 120.40,OTHER, 56.53, 214.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17224,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 98.88,,OUTPAT REV HCPCS COMBO 1, 120.40,OTHER, 56.53, 214.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17225,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 95.87,,OUTPAT REV HCPCS COMBO 1, 110.95,OTHER, 30.54, 208.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17226,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.99,,OUTPAT REV HCPCS COMBO 1, 54.17,OTHER, 9.52, 104.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17227,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.94,,OUTPAT REV HCPCS COMBO 1, 44.45,OTHER, 9.82, 84.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17228,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.94,,OUTPAT REV HCPCS COMBO 1, 44.45,OTHER, 9.82, 84.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17229,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 75.07,,OUTPAT REV HCPCS COMBO 1, 86.15,OTHER, 20.81, 162.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17230,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 122.83,,OUTPAT REV HCPCS COMBO 1, 147.00,OTHER, 59.45, 266.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17231,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 122.83,,OUTPAT REV HCPCS COMBO 1, 147.00,OTHER, 59.45, 266.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17232,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 34.31,,OUTPAT REV HCPCS COMBO 1, 43.75,OTHER, 27.89, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17233,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 166.32,,OUTPAT REV HCPCS COMBO 1, 186.61,OTHER, 28.27, 361.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17234,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.83,,OUTPAT REV HCPCS COMBO 1, 45.87,OTHER, 7.46, 92.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17235,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 42.71,,OUTPAT REV HCPCS COMBO 1, 45.87,OTHER, 7.46, 92.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17236,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 31.04,,OUTPAT REV HCPCS COMBO 1, 35.19,OTHER, 6.83, 67.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17237,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 31.04,,OUTPAT REV HCPCS COMBO 1, 35.19,OTHER, 6.83, 67.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17238,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 25.18,,OUTPAT REV HCPCS COMBO 1, 28.87,OTHER, 6.85, 54.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17239,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 11.29,,OUTPAT REV HCPCS COMBO 1, 13.83,OTHER, 6.82, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17240,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 37.50,,OUTPAT REV HCPCS COMBO 1, 45.56,OTHER, 21.01, 81.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17241,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 79.12,,OUTPAT REV HCPCS COMBO 1, 92.72,OTHER, 30.04, 171.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17242,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 79.12,,OUTPAT REV HCPCS COMBO 1, 92.72,OTHER, 30.04, 171.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17243,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 86.42,,OUTPAT REV HCPCS COMBO 1, 102.79,OTHER, 39.19, 187.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17244,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 83.70,,OUTPAT REV HCPCS COMBO 1, 97.17,OTHER, 27.91, 181.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17245,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 74.64,,OUTPAT REV HCPCS COMBO 1, 90.21,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17246,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 80.52,,OUTPAT REV HCPCS COMBO 1, 90.21,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17247,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 80.52,,OUTPAT REV HCPCS COMBO 1, 93.39,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17248,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 21.64,,OUTPAT REV HCPCS COMBO 1, 24.66,OTHER, 5.28, 46.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17249,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 21.64,,OUTPAT REV HCPCS COMBO 1, 24.66,OTHER, 5.28, 46.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17250,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 52.32,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17251,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 52.32,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17252,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 52.32,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17253,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 36.93,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17254,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 36.93,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17255,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.57,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17256,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 179.74,,OUTPAT REV HCPCS COMBO 1, 144.06,OTHER, 15.47, 390.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17257,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 79.85,,OUTPAT REV HCPCS COMBO 1, 144.06,OTHER, 15.47, 390.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17258,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 68.86,,OUTPAT REV HCPCS COMBO 1, 141.59,OTHER, 25.68, 394.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17259,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 181.67,,OUTPAT REV HCPCS COMBO 1, 141.59,OTHER, 25.68, 394.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17260,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 117.61,,OUTPAT REV HCPCS COMBO 1, 136.35,OTHER, 38.44, 255.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17261,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 86.58,,OUTPAT REV HCPCS COMBO 1, 103.27,OTHER, 40.46, 187.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17262,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 64.11,,OUTPAT REV HCPCS COMBO 1, 76.88,OTHER, 31.67, 139.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17263,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 158.93,,OUTPAT REV HCPCS COMBO 1, 178.83,OTHER, 29.15, 344.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17264,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 74.87,,OUTPAT REV HCPCS COMBO 1, 88.43,OTHER, 31.30, 162.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17265,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 26.23,,OUTPAT REV HCPCS COMBO 1, 30.02,OTHER, 6.92, 56.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17266,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 26.23,,OUTPAT REV HCPCS COMBO 1, 30.02,OTHER, 6.92, 56.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17267,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 40.80,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17268,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 40.80,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17269,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 8.38,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17270,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 160.36,,OUTPAT REV HCPCS COMBO 1, 180.72,OTHER, 30.61, 348.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17271,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 277.55,,OUTPAT REV HCPCS COMBO 1, 302.95,OTHER, 11.66, 602.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17272,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.65,,OUTPAT REV HCPCS COMBO 1, 81.90,OTHER, 36.67, 146.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17273,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 105.66,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17274,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 105.66,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17275,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 105.66,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17276,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 105.66,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17277,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 73.52,,OUTPAT REV HCPCS COMBO 1, 86.80,OTHER, 30.58, 159.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17278,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 73.52,,OUTPAT REV HCPCS COMBO 1, 86.80,OTHER, 30.58, 159.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17279,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 94.17,,OUTPAT REV HCPCS COMBO 1, 107.35,OTHER, 23.12, 204.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17280,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 94.17,,OUTPAT REV HCPCS COMBO 1, 107.35,OTHER, 23.12, 204.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17281,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.08,,OUTPAT REV HCPCS COMBO 1, 53.27,OTHER, 9.89, 102.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17282,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.08,,OUTPAT REV HCPCS COMBO 1, 53.27,OTHER, 9.89, 102.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17283,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.36,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17284,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.36,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17285,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.36,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17286,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 43.34,,OUTPAT REV HCPCS COMBO 1, 51.95,OTHER, 21.29, 94.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17287,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 62.66,,OUTPAT REV HCPCS COMBO 1, 73.53,OTHER, 24.19, 136.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17288,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 126.42,,OUTPAT REV HCPCS COMBO 1, 154.17,OTHER, 73.24, 274.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17289,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 126.42,,OUTPAT REV HCPCS COMBO 1, 154.17,OTHER, 73.24, 274.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17290,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 41.54,,OUTPAT REV HCPCS COMBO 1, 49.79,OTHER, 20.42, 90.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17291,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.79,,OUTPAT REV HCPCS COMBO 1, 38.32,OTHER, 7.46, 73.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17292,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 31.60,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, 7.63, 68.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17293,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 50.05,,OUTPAT REV HCPCS COMBO 1, 58.51,OTHER, 18.37, 108.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17294,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 34.36,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 8.27, 74.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17295,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 68.93,,OUTPAT REV HCPCS COMBO 1, 79.41,OTHER, 20.42, 149.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17296,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 68.93,,OUTPAT REV HCPCS COMBO 1, 79.41,OTHER, 20.42, 149.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17297,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.58,,OUTPAT REV HCPCS COMBO 1, 78.90,OTHER, 24.40, 146.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17298,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.58,,OUTPAT REV HCPCS COMBO 1, 78.90,OTHER, 24.40, 146.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17299,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 112.32,,OUTPAT REV HCPCS COMBO 1, 126.89,OTHER, 22.69, 243.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17300,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 72.78,,OUTPAT REV HCPCS COMBO 1, 82.99,OTHER, 17.95, 157.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17301,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 72.78,,OUTPAT REV HCPCS COMBO 1, 82.99,OTHER, 17.95, 157.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17302,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 34.92,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17303,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 34.92,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17304,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 34.92,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17305,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 19.13,,OUTPAT REV HCPCS COMBO 1, 22.60,OTHER, 8.00, 41.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17306,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 19.13,,OUTPAT REV HCPCS COMBO 1, 22.60,OTHER, 8.00, 41.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17307,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 28.04,,OUTPAT REV HCPCS COMBO 1, 31.87,OTHER, 6.50, 60.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17308,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 34.54,,OUTPAT REV HCPCS COMBO 1, 39.10,OTHER, 7.32, 74.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17309,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 66.90,,OUTPAT REV HCPCS COMBO 1, 76.33,OTHER, 16.72, 145.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17310,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 91.54,,OUTPAT REV HCPCS COMBO 1, 103.71,OTHER, 19.75, 198.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17311,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 48.80,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17312,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 48.80,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17313,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 48.80,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17314,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 72.56,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 29.96, 157.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17315,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 84.95,,OUTPAT REV HCPCS COMBO 1, 97.04,OTHER, 21.67, 184.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17316,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.12,,OUTPAT REV HCPCS COMBO 1, 42.88,OTHER, 6.94, 82.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17317,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 39.29,,OUTPAT REV HCPCS COMBO 1, 43.80,OTHER, 5.47, 85.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17318,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 15.75,,OUTPAT REV HCPCS COMBO 1, 17.85,OTHER, 3.41, 34.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17319,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 15.75,,OUTPAT REV HCPCS COMBO 1, 17.85,OTHER, 3.41, 34.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17320,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 19.09,,OUTPAT REV HCPCS COMBO 1, 21.46,OTHER, 3.41, 41.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17321,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 19.09,,OUTPAT REV HCPCS COMBO 1, 21.46,OTHER, 3.41, 41.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17322,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 22.31,OTHER, .01, 84.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17323,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.79,,OUTPAT REV HCPCS COMBO 1, 22.31,OTHER, .01, 84.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17324,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 39.29,,OUTPAT REV HCPCS COMBO 1, 44.71,OTHER, 9.31, 85.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17325,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.55,,OUTPAT REV HCPCS COMBO 1, 37.65,OTHER, 5.75, 72.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17326,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.55,,OUTPAT REV HCPCS COMBO 1, 37.65,OTHER, 5.75, 72.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17327,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 17.61,,OUTPAT REV HCPCS COMBO 1, 19.92,OTHER, 3.66, 38.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17328,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 28.75,,OUTPAT REV HCPCS COMBO 1, 32.63,OTHER, 6.46, 62.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17329,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 83.80,,OUTPAT REV HCPCS COMBO 1, 96.77,OTHER, 25.78, 181.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17330,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 112.28,,OUTPAT REV HCPCS COMBO 1, 129.31,OTHER, 33.04, 243.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17331,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 116.94,,OUTPAT REV HCPCS COMBO 1, 130.54,OTHER, 17.06, 253.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17332,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 86.54,,OUTPAT REV HCPCS COMBO 1, 98.34,OTHER, 19.93, 187.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17333,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 77.43,,OUTPAT REV HCPCS COMBO 1, 89.00,OTHER, 22.06, 168.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17334,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 87.59,,OUTPAT REV HCPCS COMBO 1, 98.22,OTHER, 14.66, 190.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17335,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.43,,OUTPAT REV HCPCS COMBO 1, 54.63,OTHER, 13.99, 102.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17336,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 59.15,,OUTPAT REV HCPCS COMBO 1, 70.40,OTHER, 27.00, 128.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17337,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 26.30,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17338,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 26.13,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17339,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 26.30,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17340,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 11.74,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17341,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 11.74,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17342,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 11.74,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17343,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 11.74,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17344,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 37.11,,OUTPAT REV HCPCS COMBO 1, 41.60,OTHER, 6.14, 80.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17345,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 23.48,,OUTPAT REV HCPCS COMBO 1, 26.32,OTHER, 3.89, 50.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17346,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 31.86,,OUTPAT REV HCPCS COMBO 1, 36.35,OTHER, 7.93, 69.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17347,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 76.76,,OUTPAT REV HCPCS COMBO 1, 61.85,OTHER, 8.65, 166.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17348,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.81,,OUTPAT REV HCPCS COMBO 1, 61.85,OTHER, 8.65, 166.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17349,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 68.41,,OUTPAT REV HCPCS COMBO 1, 76.67,OTHER, 11.26, 148.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17350,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 536.54,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17351,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 145.83,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17352,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17353,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17354,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17355,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17356,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17357,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17358,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17359,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17360,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17361,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17362,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17363,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17364,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17365,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17366,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17367,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17368,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17369,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17370,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17371,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17372,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17373,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17374,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17375,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17376,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17377,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17378,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17379,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17380,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17381,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17382,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17383,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17384,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17385,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17386,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17387,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17388,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 27.83,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17389,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17390,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17391,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17392,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17393,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 14.49,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17394,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17395,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17396,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17397,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17398,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17399,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17400,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17401,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17402,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17403,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17404,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17405,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17406,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17407,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17408,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17409,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17410,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17411,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17412,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 169.20,,OUTPAT REV HCPCS COMBO 1, 189.29,OTHER, 26.45, 367.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17413,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 103.31,,OUTPAT REV HCPCS COMBO 1, 115.17,OTHER, 14.46, 224.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17414,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 60.18,,OUTPAT REV HCPCS COMBO 1, 91.70,OTHER, 17.41, 220.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17415,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 101.71,,OUTPAT REV HCPCS COMBO 1, 91.70,OTHER, 17.41, 220.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17416,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 41.69,,OUTPAT REV HCPCS COMBO 1, 48.91,OTHER, 16.07, 90.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17417,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 39.51,,OUTPAT REV HCPCS COMBO 1, 45.23,OTHER, 10.51, 85.75,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17418,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 14.15,,OUTPAT REV HCPCS COMBO 1, 17.08,OTHER, 7.46, 30.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17419,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 14.15,,OUTPAT REV HCPCS COMBO 1, 17.08,OTHER, 7.46, 30.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17420,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 50.68,,OUTPAT REV HCPCS COMBO 1, 59.25,OTHER, 18.65, 110.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17421,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 78.83,,OUTPAT REV HCPCS COMBO 1, 93.98,OTHER, 36.65, 171.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17422,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 118.95,,OUTPAT REV HCPCS COMBO 1, 137.37,OTHER, 36.65, 258.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17423,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.45,,OUTPAT REV HCPCS COMBO 1, 78.46,OTHER, 23.14, 146.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17424,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 58.81,,OUTPAT REV HCPCS COMBO 1, 67.64,OTHER, 17.28, 127.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17425,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 58.66,,OUTPAT REV HCPCS COMBO 1, 67.64,OTHER, 17.28, 127.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17426,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 65.39,,OUTPAT REV HCPCS COMBO 1, 77.69,OTHER, 29.26, 141.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17427,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 54.32,,OUTPAT REV HCPCS COMBO 1, 63.19,OTHER, 18.65, 117.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17428,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 54.24,,OUTPAT REV HCPCS COMBO 1, 65.88,OTHER, 19.79, 127.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17429,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 58.88,,OUTPAT REV HCPCS COMBO 1, 65.88,OTHER, 19.79, 127.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17430,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 63.86,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17431,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 63.86,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17432,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 63.86,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17433,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 63.86,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17434,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 63.94,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17435,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 63.86,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17436,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 54.56,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17437,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 50.87,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17438,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 71.79,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17439,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 109.79,,OUTPAT REV HCPCS COMBO 1, 120.82,OTHER, 17.35, 238.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17440,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 105.99,,OUTPAT REV HCPCS COMBO 1, 120.82,OTHER, 17.35, 238.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17441,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 11.29,,OUTPAT REV HCPCS COMBO 1, 15.65,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17442,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.29,,OUTPAT REV HCPCS COMBO 1, 80.94,OTHER, 29.96, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17443,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.19,,OUTPAT REV HCPCS COMBO 1, 80.94,OTHER, 29.96, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17444,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 72.11,,OUTPAT REV HCPCS COMBO 1, 85.12,OTHER, 29.96, 156.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17445,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 89.05,,OUTPAT REV HCPCS COMBO 1, 103.45,OTHER, 29.96, 193.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17446,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 61.09,,OUTPAT REV HCPCS COMBO 1, 125.05,OTHER, 24.97, 345.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17447,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 159.15,,OUTPAT REV HCPCS COMBO 1, 125.05,OTHER, 24.97, 345.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17448,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 45.09,,OUTPAT REV HCPCS COMBO 1, 50.54,OTHER, 7.46, 97.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17449,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 75.09,,OUTPAT REV HCPCS COMBO 1, 88.87,OTHER, 32.17, 162.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17450,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 54.63,,OUTPAT REV HCPCS COMBO 1, 66.43,OTHER, 30.83, 118.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17451,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 48.32,,OUTPAT REV HCPCS COMBO 1, 57.43,OTHER, 21.72, 104.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17452,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 237.60,,OUTPAT REV HCPCS COMBO 1, 265.06,OTHER, 33.95, 515.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17453,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 66.37,,OUTPAT REV HCPCS COMBO 1, 80.97,OTHER, 38.57, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17454,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 66.37,,OUTPAT REV HCPCS COMBO 1, 80.97,OTHER, 38.57, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17455,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 91.43,,OUTPAT REV HCPCS COMBO 1, 111.82,OTHER, 54.34, 198.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17456,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 148.05,,OUTPAT REV HCPCS COMBO 1, 176.22,OTHER, 67.64, 321.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17457,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 72.92,,OUTPAT REV HCPCS COMBO 1, 88.05,OTHER, 38.57, 158.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17458,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 72.92,,OUTPAT REV HCPCS COMBO 1, 88.05,OTHER, 38.57, 158.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17459,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 60.50,,OUTPAT REV HCPCS COMBO 1, 68.73,OTHER, 13.84, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17460,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 73.65,,OUTPAT REV HCPCS COMBO 1, 96.09,OTHER, 20.95, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17461,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 94.82,,OUTPAT REV HCPCS COMBO 1, 96.09,OTHER, 20.95, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17462,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 60.50,,OUTPAT REV HCPCS COMBO 1, 70.10,OTHER, 19.60, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17463,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 41.53,,OUTPAT REV HCPCS COMBO 1, 46.86,OTHER, 8.16, 90.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17464,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 41.53,,OUTPAT REV HCPCS COMBO 1, 46.86,OTHER, 8.16, 90.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17465,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.57,,OUTPAT REV HCPCS COMBO 1, 191.67,OTHER, 89.24, 342.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17466,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 8.44,,OUTPAT REV HCPCS COMBO 1, 12.31,OTHER, 8.04, 18.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17467,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 15.76,,OUTPAT REV HCPCS COMBO 1, 18.56,OTHER, 6.34, 34.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17468,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 28.71,,OUTPAT REV HCPCS COMBO 1, 36.21,OTHER, 21.67, 62.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17469,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.86,,OUTPAT REV HCPCS COMBO 1, 55.25,OTHER, 14.66, 103.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17470,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.01,,OUTPAT REV HCPCS COMBO 1, 40.13,OTHER, 18.58, 71.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17471,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 57.34,,OUTPAT REV HCPCS COMBO 1, 66.54,OTHER, 19.00, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17472,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 76.32,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17473,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 76.32,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17474,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 76.32,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17475,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 20.92,,OUTPAT REV HCPCS COMBO 1, 26.75,OTHER, 17.29, 45.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17476,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 43.76,,OUTPAT REV HCPCS COMBO 1, 91.08,OTHER, 16.51, 254.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17477,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 117.39,,OUTPAT REV HCPCS COMBO 1, 91.08,OTHER, 16.51, 254.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17478,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 42.44,,OUTPAT REV HCPCS COMBO 1, 50.83,OTHER, 20.72, 92.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17479,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 49.21,,OUTPAT REV HCPCS COMBO 1, 59.00,OTHER, 24.26, 106.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17480,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 54.75,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 22.02, 118.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17481,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 49.26,,OUTPAT REV HCPCS COMBO 1, 59.50,OTHER, 26.12, 106.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17482,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 49.26,,OUTPAT REV HCPCS COMBO 1, 59.50,OTHER, 26.12, 106.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17483,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 82.62,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17484,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 49.72,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17485,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 49.72,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17486,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 55.53,,OUTPAT REV HCPCS COMBO 1, 66.70,OTHER, 27.86, 120.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17487,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 55.53,,OUTPAT REV HCPCS COMBO 1, 66.70,OTHER, 27.86, 120.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17488,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 35.67,,OUTPAT REV HCPCS COMBO 1, 43.51,OTHER, 20.72, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17489,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 39.90,,OUTPAT REV HCPCS COMBO 1, 47.68,OTHER, 19.00, 86.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17490,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.86,,OUTPAT REV HCPCS COMBO 1, 58.39,OTHER, 27.86, 103.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17491,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.26,,OUTPAT REV HCPCS COMBO 1, 77.47,OTHER, 19.86, 145.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17492,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 53.44,,OUTPAT REV HCPCS COMBO 1, 62.50,OTHER, 19.74, 116.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17493,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 39.40,,OUTPAT REV HCPCS COMBO 1, 46.75,OTHER, 17.35, 85.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17494,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 34.31,,OUTPAT REV HCPCS COMBO 1, 41.14,OTHER, 16.94, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17495,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 58.62,,OUTPAT REV HCPCS COMBO 1, 67.08,OTHER, 15.47, 127.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17496,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 42.79,,OUTPAT REV HCPCS COMBO 1, 50.52,OTHER, 17.84, 92.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17497,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 22.48,,OUTPAT REV HCPCS COMBO 1, 28.18,OTHER, 16.21, 48.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17498,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 44.45,,OUTPAT REV HCPCS COMBO 1, 52.54,OTHER, 18.79, 96.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17499,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 44.45,,OUTPAT REV HCPCS COMBO 1, 52.54,OTHER, 18.79, 96.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17500,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.86,,OUTPAT REV HCPCS COMBO 1, 41.16,OTHER, 19.07, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17501,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.07,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17502,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.07,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17503,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.07,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17504,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 39.39,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17505,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 40.75,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17506,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 40.75,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17507,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 41.46,,OUTPAT REV HCPCS COMBO 1, 49.38,OTHER, 19.07, 89.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17508,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.99,,OUTPAT REV HCPCS COMBO 1, 80.11,OTHER, 18.55, 151.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17509,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.99,,OUTPAT REV HCPCS COMBO 1, 80.11,OTHER, 18.55, 151.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17510,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 330.40,,OUTPAT REV HCPCS COMBO 1, 361.76,OTHER, 18.55, 717.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17511,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 144.93,,OUTPAT REV HCPCS COMBO 1, 161.64,OTHER, 20.54, 314.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17512,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 126.32,,OUTPAT REV HCPCS COMBO 1, 158.63,OTHER, 92.44, 274.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17513,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 126.32,,OUTPAT REV HCPCS COMBO 1, 158.63,OTHER, 92.44, 274.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17514,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.03,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17515,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.03,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17516,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.03,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17517,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 107.91,,OUTPAT REV HCPCS COMBO 1, 152.44,OTHER, 102.77, 234.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17518,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 194.53,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17519,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 194.53,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17520,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 194.53,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17521,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 73.89,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17522,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 73.89,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17523,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 73.89,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17524,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 73.89,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17525,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 73.89,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17526,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 134.15,,OUTPAT REV HCPCS COMBO 1, 146.86,OTHER, 7.46, 291.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17527,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 49.67,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17528,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 49.67,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17529,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 49.67,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17530,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 41.12,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17531,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 39.08,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17532,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 41.12,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17533,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 194.53,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17534,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 194.53,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17535,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 176.76,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17536,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 62.98,,OUTPAT REV HCPCS COMBO 1, 70.78,OTHER, 11.16, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17537,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 62.98,,OUTPAT REV HCPCS COMBO 1, 70.78,OTHER, 11.16, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17538,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 268.29,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17539,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 268.29,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17540,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 268.29,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17541,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 268.29,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17542,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 268.29,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17543,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 268.29,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17544,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 62.98,,OUTPAT REV HCPCS COMBO 1, 76.50,OTHER, 35.20, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17545,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 117.84,,OUTPAT REV HCPCS COMBO 1, 149.18,OTHER, 91.25, 255.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17546,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 72.00,,OUTPAT REV HCPCS COMBO 1, 81.41,OTHER, 14.86, 156.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17547,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 72.00,,OUTPAT REV HCPCS COMBO 1, 81.41,OTHER, 14.86, 156.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17548,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 25.45,,OUTPAT REV HCPCS COMBO 1, 30.76,OTHER, 13.60, 55.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17549,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 64.43,,OUTPAT REV HCPCS COMBO 1, 72.64,OTHER, 12.41, 139.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17550,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 64.43,,OUTPAT REV HCPCS COMBO 1, 72.64,OTHER, 12.41, 139.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17551,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.36,,OUTPAT REV HCPCS COMBO 1, 78.26,OTHER, 13.63, 150.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17552,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.36,,OUTPAT REV HCPCS COMBO 1, 78.26,OTHER, 13.63, 150.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17553,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 70.47,,OUTPAT REV HCPCS COMBO 1, 78.99,OTHER, 11.64, 152.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17554,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 40.68,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17555,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 40.68,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17556,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 40.68,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17557,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 35.77,,OUTPAT REV HCPCS COMBO 1, 40.96,OTHER, 9.55, 77.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17558,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.75,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17559,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.75,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17560,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.75,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17561,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 73.50,,OUTPAT REV HCPCS COMBO 1, 82.26,OTHER, 11.65, 159.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17562,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 73.50,,OUTPAT REV HCPCS COMBO 1, 82.26,OTHER, 11.65, 159.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17563,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 66.44,,OUTPAT REV HCPCS COMBO 1, 74.74,OTHER, 12.11, 144.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17564,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 80.72,,OUTPAT REV HCPCS COMBO 1, 91.00,OTHER, 15.55, 175.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17565,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 60.34,,OUTPAT REV HCPCS COMBO 1, 68.31,OTHER, 12.82, 130.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17566,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 14.90,,OUTPAT REV HCPCS COMBO 1, 17.74,OTHER, 6.84, 32.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17567,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 18.89,,OUTPAT REV HCPCS COMBO 1, 22.99,OTHER, 10.78, 40.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17568,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 26.19,,OUTPAT REV HCPCS COMBO 1, 29.95,OTHER, 6.84, 56.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17569,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 36.47,,OUTPAT REV HCPCS COMBO 1, 42.41,OTHER, 12.46, 79.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17570,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 25.55,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17571,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 23.79,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17572,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 23.79,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17573,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 23.88,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17574,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 23.88,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17575,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.56,,OUTPAT REV HCPCS COMBO 1, 38.14,OTHER, 7.76, 72.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17576,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.56,,OUTPAT REV HCPCS COMBO 1, 38.14,OTHER, 7.76, 72.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17577,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 24.31,,OUTPAT REV HCPCS COMBO 1, 28.29,OTHER, 8.38, 52.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17578,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 57.34,,OUTPAT REV HCPCS COMBO 1, 68.72,OTHER, 28.16, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17579,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 273.02,,OUTPAT REV HCPCS COMBO 1, 299.39,OTHER, 17.26, 592.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17580,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 34.32,,OUTPAT REV HCPCS COMBO 1, 40.67,OTHER, 14.88, 74.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17581,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 36.17,,OUTPAT REV HCPCS COMBO 1, 43.08,OTHER, 16.61, 78.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17582,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 107.91,,OUTPAT REV HCPCS COMBO 1, 121.25,OTHER, 19.08, 234.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17583,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 57.34,,OUTPAT REV HCPCS COMBO 1, 68.89,OTHER, 28.87, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17584,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 87.14,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17585,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 87.14,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17586,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 87.14,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17587,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 87.14,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17588,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 87.14,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17589,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 170.28,,OUTPAT REV HCPCS COMBO 1, 198.86,OTHER, 61.69, 369.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17590,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 170.28,,OUTPAT REV HCPCS COMBO 1, 198.86,OTHER, 61.69, 369.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17591,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 70.94,,OUTPAT REV HCPCS COMBO 1, 100.71,OTHER, 67.57, 153.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17592,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 191.20,,OUTPAT REV HCPCS COMBO 1, 221.47,OTHER, 61.69, 415.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17593,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 59.55,,OUTPAT REV HCPCS COMBO 1, 76.43,OTHER, 50.53, 129.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17594,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 218.07,,OUTPAT REV HCPCS COMBO 1, 265.03,OTHER, 122.54, 473.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17595,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 87.14,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17596,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.73,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17597,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.73,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17598,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 279.96,,OUTPAT REV HCPCS COMBO 1, 445.68,OTHER, 266.63, 607.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17599,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17600,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17601,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17602,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 168.24,,OUTPAT REV HCPCS COMBO 1, 193.99,OTHER, 50.53, 365.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17603,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 168.24,,OUTPAT REV HCPCS COMBO 1, 193.99,OTHER, 50.53, 365.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17604,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17605,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 149.45,,OUTPAT REV HCPCS COMBO 1, 173.66,OTHER, 50.53, 324.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17606,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 57.34,,OUTPAT REV HCPCS COMBO 1, 68.89,OTHER, 28.87, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17607,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 79.10,,OUTPAT REV HCPCS COMBO 1, 204.22,OTHER, 50.53, 599.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17608,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 276.29,,OUTPAT REV HCPCS COMBO 1, 204.22,OTHER, 50.53, 599.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17609,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 121.89,,OUTPAT REV HCPCS COMBO 1, 146.52,OTHER, 61.69, 264.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17610,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 121.89,,OUTPAT REV HCPCS COMBO 1, 146.52,OTHER, 61.69, 264.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17611,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 52.32,,OUTPAT REV HCPCS COMBO 1, 62.25,OTHER, 23.83, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17612,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 52.32,,OUTPAT REV HCPCS COMBO 1, 62.25,OTHER, 23.83, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17613,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 35.67,,OUTPAT REV HCPCS COMBO 1, 43.07,OTHER, 18.86, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17614,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 35.67,,OUTPAT REV HCPCS COMBO 1, 43.07,OTHER, 18.86, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17615,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 35.67,,OUTPAT REV HCPCS COMBO 1, 44.25,OTHER, 23.81, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17616,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 11.29,,OUTPAT REV HCPCS COMBO 1, 17.88,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17617,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 87.50,,OUTPAT REV HCPCS COMBO 1, 100.14,OTHER, 23.14, 189.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17618,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 658.74,,OUTPAT REV HCPCS COMBO 1, 800.72,OTHER, 370.73, 1429.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17619,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 658.74,,OUTPAT REV HCPCS COMBO 1, 800.72,OTHER, 370.73, 1429.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17620,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 46.96,,OUTPAT REV HCPCS COMBO 1, 59.91,OTHER, 38.32, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17621,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 46.96,,OUTPAT REV HCPCS COMBO 1, 59.91,OTHER, 38.32, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17622,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 250.58,,OUTPAT REV HCPCS COMBO 1, 294.34,OTHER, 97.97, 543.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17623,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17624,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17625,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 14.00,,OUTPAT REV HCPCS COMBO 1, 16.75,OTHER, 6.79, 30.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17626,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 14.00,,OUTPAT REV HCPCS COMBO 1, 16.75,OTHER, 6.79, 30.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17627,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 50.75,,OUTPAT REV HCPCS COMBO 1, 56.81,OTHER, 8.06, 110.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17628,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 34.64,,OUTPAT REV HCPCS COMBO 1, 39.98,OTHER, 10.56, 75.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17629,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 34.77,,OUTPAT REV HCPCS COMBO 1, 41.73,OTHER, 17.35, 75.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17630,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2678.49,,OUTPAT REV HCPCS COMBO 1, 3802.17,OTHER, 2550.94, 5813.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17631,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 50.87,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17632,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 50.87,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17633,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 13.32,,OUTPAT REV HCPCS COMBO 1, 23.30,OTHER, 12.69, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17634,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 26.86,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17635,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 13.43,,OUTPAT REV HCPCS COMBO 1, 23.42,OTHER, 12.79, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17636,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 58.24,,OUTPAT REV HCPCS COMBO 1, 82.68,OTHER, 55.47, 126.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17637,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17638,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.08,,OUTPAT REV HCPCS COMBO 1, 149.84,OTHER, 65.79, 315.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17639,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.08,,OUTPAT REV HCPCS COMBO 1, 149.84,OTHER, 65.79, 315.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17640,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 62.74,,OUTPAT REV HCPCS COMBO 1, 89.06,OTHER, 59.75, 136.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17641,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 22.58,,OUTPAT REV HCPCS COMBO 1, 41.40,OTHER, 21.50, 71.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17642,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 22.58,,OUTPAT REV HCPCS COMBO 1, 41.40,OTHER, 21.50, 71.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17643,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 267.92,,OUTPAT REV HCPCS COMBO 1, 356.50,OTHER, 255.16, 581.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17644,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 559.77,,OUTPAT REV HCPCS COMBO 1, 687.64,OTHER, 345.38, 1214.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17645,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 142.00,,OUTPAT REV HCPCS COMBO 1, 201.57,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17646,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17647,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17648,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.38,,OUTPAT REV HCPCS COMBO 1, 60.00,OTHER, 36.55, 83.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17649,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 23.23,,OUTPAT REV HCPCS COMBO 1, 36.74,OTHER, 22.12, 50.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17650,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 23.23,,OUTPAT REV HCPCS COMBO 1, 36.74,OTHER, 22.12, 50.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17651,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17652,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17653,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17654,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 4.97,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17655,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 4.97,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17656,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 4.97,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17657,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 4.97,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17658,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 36.00,,OUTPAT REV HCPCS COMBO 1, 51.11,OTHER, 34.29, 78.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17659,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 61.72,,OUTPAT REV HCPCS COMBO 1, 87.62,OTHER, 58.79, 133.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17660,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 61.72,,OUTPAT REV HCPCS COMBO 1, 87.62,OTHER, 58.79, 133.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17661,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17662,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 71.25,,OUTPAT REV HCPCS COMBO 1, 111.30,OTHER, 67.85, 154.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17663,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 71.25,,OUTPAT REV HCPCS COMBO 1, 111.30,OTHER, 67.85, 154.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17664,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17665,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17666,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 77.17,,OUTPAT REV HCPCS COMBO 1, 104.75,OTHER, 73.49, 167.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17667,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 77.17,,OUTPAT REV HCPCS COMBO 1, 104.75,OTHER, 73.49, 167.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17668,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 4.52,,OUTPAT REV HCPCS COMBO 1, 12.78,OTHER, 4.30, 33.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17669,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 14.93,,OUTPAT REV HCPCS COMBO 1, 17.36,OTHER, 5.09, 32.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17670,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 137.22,,OUTPAT REV HCPCS COMBO 1, 184.48,OTHER, 130.68, 297.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17671,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 153.74,,OUTPAT REV HCPCS COMBO 1, 202.35,OTHER, 146.42, 333.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17672,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 66.79,,OUTPAT REV HCPCS COMBO 1, 99.37,OTHER, 63.61, 144.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17673,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 68.66,,OUTPAT REV HCPCS COMBO 1, 88.44,OTHER, 59.56, 149.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17674,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 88.44,,OUTPAT REV HCPCS COMBO 1, 131.72,OTHER, 84.22, 191.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17675,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 86.95,,OUTPAT REV HCPCS COMBO 1, 117.05,OTHER, 82.81, 188.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17676,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 132.84,,OUTPAT REV HCPCS COMBO 1, 179.75,OTHER, 126.51, 288.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17677,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 114.93,,OUTPAT REV HCPCS COMBO 1, 158.52,OTHER, 109.46, 249.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17678,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 138.81,,OUTPAT REV HCPCS COMBO 1, 186.21,OTHER, 132.20, 301.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17679,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 66.42,,OUTPAT REV HCPCS COMBO 1, 83.96,OTHER, 50.93, 144.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17680,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 107.10,,OUTPAT REV HCPCS COMBO 1, 167.44,OTHER, 102.00, 232.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17681,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 111.57,,OUTPAT REV HCPCS COMBO 1, 172.28,OTHER, 106.26, 242.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17682,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 26.87,,OUTPAT REV HCPCS COMBO 1, 49.86,OTHER, 25.59, 87.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17683,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 111.94,,OUTPAT REV HCPCS COMBO 1, 141.43,OTHER, 85.51, 242.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17684,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.69,,OUTPAT REV HCPCS COMBO 1, 69.71,OTHER, 45.42, 103.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17685,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 126.50,,OUTPAT REV HCPCS COMBO 1, 177.65,OTHER, 120.47, 274.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17686,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 137.41,,OUTPAT REV HCPCS COMBO 1, 189.46,OTHER, 130.87, 298.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17687,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 221.06,,OUTPAT REV HCPCS COMBO 1, 279.93,OTHER, 171.54, 479.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17688,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 207.26,,OUTPAT REV HCPCS COMBO 1, 265.00,OTHER, 171.54, 449.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17689,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 113.59,,OUTPAT REV HCPCS COMBO 1, 149.90,OTHER, 108.18, 246.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17690,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 144.28,,OUTPAT REV HCPCS COMBO 1, 167.02,OTHER, 46.09, 313.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17691,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 60.22,,OUTPAT REV HCPCS COMBO 1, 76.10,OTHER, 46.09, 130.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17692,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 126.09,,OUTPAT REV HCPCS COMBO 1, 147.35,OTHER, 46.09, 273.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17693,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 182.72,,OUTPAT REV HCPCS COMBO 1, 227.22,OTHER, 124.32, 396.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17694,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 245.84,,OUTPAT REV HCPCS COMBO 1, 295.49,OTHER, 124.32, 533.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17695,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 78.40,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 74.67, 170.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17696,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 116.39,,OUTPAT REV HCPCS COMBO 1, 155.48,OTHER, 110.85, 252.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17697,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 18.04,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17698,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 18.04,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17699,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 18.04,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17700,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 8.83,,OUTPAT REV HCPCS COMBO 1, 36.72,OTHER, 8.41, 114.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17701,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 166.31,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 114.13, 360.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17702,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 166.31,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 114.13, 360.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17703,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 410.70,,OUTPAT REV HCPCS COMBO 1, 526.62,OTHER, 346.21, 891.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17704,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17705,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17706,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 139.06,,OUTPAT REV HCPCS COMBO 1, 162.12,OTHER, 49.24, 301.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17707,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 111.97,,OUTPAT REV HCPCS COMBO 1, 140.39,OTHER, 80.99, 243.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17708,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 111.97,,OUTPAT REV HCPCS COMBO 1, 140.39,OTHER, 80.99, 243.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17709,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 143.13,,OUTPAT REV HCPCS COMBO 1, 166.97,OTHER, 51.13, 310.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17710,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 39.56,,OUTPAT REV HCPCS COMBO 1, 54.96,OTHER, 37.67, 85.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17711,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 68.66,,OUTPAT REV HCPCS COMBO 1, 86.43,OTHER, 51.13, 149.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17712,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 734.45,,OUTPAT REV HCPCS COMBO 1, 950.56,OTHER, 656.16, 1594.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17713,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17714,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 419.90,,OUTPAT REV HCPCS COMBO 1, 545.72,OTHER, 384.68, 911.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17715,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 419.90,,OUTPAT REV HCPCS COMBO 1, 545.72,OTHER, 384.68, 911.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17716,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17717,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17718,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 497.67,,OUTPAT REV HCPCS COMBO 1, 591.97,OTHER, 225.62, 1080.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17719,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17720,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 210.26,,OUTPAT REV HCPCS COMBO 1, 250.40,OTHER, 96.59, 456.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17721,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 210.26,,OUTPAT REV HCPCS COMBO 1, 250.40,OTHER, 96.59, 456.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17722,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17723,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 471.49,,OUTPAT REV HCPCS COMBO 1, 563.65,OTHER, 225.62, 1023.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17724,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17725,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 73.59,,OUTPAT REV HCPCS COMBO 1, 113.30,OTHER, 70.09, 159.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17726,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 73.59,,OUTPAT REV HCPCS COMBO 1, 113.30,OTHER, 70.09, 159.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17727,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17728,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17729,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 225.75,,OUTPAT REV HCPCS COMBO 1, 297.88,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17730,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17731,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 211.19,,OUTPAT REV HCPCS COMBO 1, 262.11,OTHER, 141.55, 458.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17732,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 211.19,,OUTPAT REV HCPCS COMBO 1, 262.11,OTHER, 141.55, 458.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17733,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17734,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17735,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 573.16,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17736,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 573.16,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17737,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 304.53,,OUTPAT REV HCPCS COMBO 1, 383.08,OTHER, 225.62, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17738,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 573.16,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17739,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17740,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17741,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17742,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17743,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 304.53,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17744,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 304.53,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17745,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 304.53,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17746,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 304.53,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17747,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17748,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17749,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17750,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17751,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 556.31,,OUTPAT REV HCPCS COMBO 1, 655.39,OTHER, 225.62, 1207.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17752,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17753,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1169.84,,OUTPAT REV HCPCS COMBO 1, 1042.14,OTHER, 284.89, 2539.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17754,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 631.87,,OUTPAT REV HCPCS COMBO 1, 1042.14,OTHER, 284.89, 2539.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17755,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 196.85,,OUTPAT REV HCPCS COMBO 1, 184.77,OTHER, 39.56, 427.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17756,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 41.54,,OUTPAT REV HCPCS COMBO 1, 184.77,OTHER, 39.56, 427.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17757,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 475.60,,OUTPAT REV HCPCS COMBO 1, 547.41,OTHER, 138.71, 1032.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17758,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 109.08,,OUTPAT REV HCPCS COMBO 1, 154.36,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17759,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 109.08,,OUTPAT REV HCPCS COMBO 1, 154.36,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17760,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 132.08,,OUTPAT REV HCPCS COMBO 1, 199.86,OTHER, 125.79, 286.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17761,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 132.08,,OUTPAT REV HCPCS COMBO 1, 199.86,OTHER, 125.79, 286.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17762,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 276.49,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17763,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 362.55,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17764,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 398.22,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17765,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 276.49,,OUTPAT REV HCPCS COMBO 1, 332.46,OTHER, 140.42, 600.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17766,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 168.30,,OUTPAT REV HCPCS COMBO 1, 239.03,OTHER, 160.29, 365.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17767,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 168.30,,OUTPAT REV HCPCS COMBO 1, 239.03,OTHER, 160.29, 365.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17768,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 109.08,,OUTPAT REV HCPCS COMBO 1, 174.98,OTHER, 103.88, 239.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17769,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 109.08,,OUTPAT REV HCPCS COMBO 1, 136.10,OTHER, 76.16, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17770,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 78.11,,OUTPAT REV HCPCS COMBO 1, 140.33,OTHER, 74.39, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17771,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 191.89,,OUTPAT REV HCPCS COMBO 1, 228.33,OTHER, 87.35, 416.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17772,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 24.08,,OUTPAT REV HCPCS COMBO 1, 34.19,OTHER, 22.94, 52.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17773,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 46.96,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17774,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 147.93,,OUTPAT REV HCPCS COMBO 1, 182.46,OTHER, 94.34, 321.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17775,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 147.93,,OUTPAT REV HCPCS COMBO 1, 182.46,OTHER, 94.34, 321.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17776,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 64.76,,OUTPAT REV HCPCS COMBO 1, 125.89,OTHER, 61.67, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17777,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 64.76,,OUTPAT REV HCPCS COMBO 1, 125.89,OTHER, 61.67, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17778,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 332.39,,OUTPAT REV HCPCS COMBO 1, 415.63,OTHER, 235.80, 721.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17779,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1467.38,,OUTPAT REV HCPCS COMBO 1, 1853.96,OTHER, 1121.15, 3185.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17780,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1467.38,,OUTPAT REV HCPCS COMBO 1, 1853.96,OTHER, 1121.15, 3185.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17781,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1760.85,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17782,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1760.85,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17783,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1760.85,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17784,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 122.46,,OUTPAT REV HCPCS COMBO 1, 152.82,OTHER, 85.61, 265.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17785,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 133.77,,OUTPAT REV HCPCS COMBO 1, 165.98,OTHER, 89.47, 290.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17786,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 216.84,,OUTPAT REV HCPCS COMBO 1, 260.74,OTHER, 110.12, 470.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17787,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 216.84,,OUTPAT REV HCPCS COMBO 1, 260.74,OTHER, 110.12, 470.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17788,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 81.36,,OUTPAT REV HCPCS COMBO 1, 96.89,OTHER, 37.34, 176.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17789,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 81.36,,OUTPAT REV HCPCS COMBO 1, 96.89,OTHER, 37.34, 176.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17790,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 258.10,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17791,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 258.10,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17792,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 258.10,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17793,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 74.36,,OUTPAT REV HCPCS COMBO 1, 89.33,OTHER, 37.34, 161.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17794,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 74.39,,OUTPAT REV HCPCS COMBO 1, 89.33,OTHER, 37.34, 161.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17795,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 88.69,,OUTPAT REV HCPCS COMBO 1, 108.89,OTHER, 54.48, 192.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17796,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 88.69,,OUTPAT REV HCPCS COMBO 1, 108.89,OTHER, 54.48, 192.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17797,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 64.99,,OUTPAT REV HCPCS COMBO 1, 92.25,OTHER, 61.89, 141.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17798,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 64.99,,OUTPAT REV HCPCS COMBO 1, 92.25,OTHER, 61.89, 141.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17799,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.48,,OUTPAT REV HCPCS COMBO 1, 84.04,OTHER, 37.34, 150.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17800,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.48,,OUTPAT REV HCPCS COMBO 1, 84.04,OTHER, 37.34, 150.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17801,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 26.86,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17802,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 26.86,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17803,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 135.83,,OUTPAT REV HCPCS COMBO 1, 159.88,OTHER, 54.48, 294.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17804,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 135.83,,OUTPAT REV HCPCS COMBO 1, 159.88,OTHER, 54.48, 294.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17805,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 77.17,,OUTPAT REV HCPCS COMBO 1, 96.44,OTHER, 54.48, 167.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17806,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 77.17,,OUTPAT REV HCPCS COMBO 1, 96.44,OTHER, 54.48, 167.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17807,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 77.88,,OUTPAT REV HCPCS COMBO 1, 110.56,OTHER, 74.18, 169.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17808,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 77.88,,OUTPAT REV HCPCS COMBO 1, 110.56,OTHER, 74.18, 169.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17809,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 39.71,,OUTPAT REV HCPCS COMBO 1, 47.95,OTHER, 21.01, 86.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17810,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 39.71,,OUTPAT REV HCPCS COMBO 1, 47.95,OTHER, 21.01, 86.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17811,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 43.59,,OUTPAT REV HCPCS COMBO 1, 55.33,OTHER, 34.39, 94.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17812,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 43.59,,OUTPAT REV HCPCS COMBO 1, 55.33,OTHER, 34.39, 94.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17813,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.76,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17814,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.76,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17815,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.76,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17816,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 189.63,,OUTPAT REV HCPCS COMBO 1, 142.33,OTHER, 28.82, 411.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17817,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 60.88,,OUTPAT REV HCPCS COMBO 1, 142.33,OTHER, 28.82, 411.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17818,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 60.88,,OUTPAT REV HCPCS COMBO 1, 72.71,OTHER, 28.82, 132.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17819,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 55.48,,OUTPAT REV HCPCS COMBO 1, 74.33,OTHER, 52.80, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17820,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 55.44,,OUTPAT REV HCPCS COMBO 1, 74.33,OTHER, 52.80, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17821,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 55.48,,OUTPAT REV HCPCS COMBO 1, 74.35,OTHER, 52.84, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17822,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 59.17,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17823,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 59.17,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17824,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 59.17,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17825,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 42.95,,OUTPAT REV HCPCS COMBO 1, 60.80,OTHER, 40.91, 93.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17826,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 42.95,,OUTPAT REV HCPCS COMBO 1, 60.80,OTHER, 40.91, 93.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17827,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.53,,OUTPAT REV HCPCS COMBO 1, 47.68,OTHER, 29.08, 66.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17828,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 80.82,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17829,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 80.82,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17830,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 80.82,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17831,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 97.07,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17832,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 97.07,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17833,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 97.07,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17834,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 55.39,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17835,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 55.39,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17836,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 55.39,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17837,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 19.87,,OUTPAT REV HCPCS COMBO 1, 30.33,OTHER, 18.92, 43.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17838,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 119.67,,OUTPAT REV HCPCS COMBO 1, 178.52,OTHER, 113.97, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17839,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 142.00,,OUTPAT REV HCPCS COMBO 1, 202.67,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17840,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 134.44,,OUTPAT REV HCPCS COMBO 1, 194.50,OTHER, 128.04, 291.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17841,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 66.98,,OUTPAT REV HCPCS COMBO 1, 106.37,OTHER, 63.79, 145.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17842,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 114.83,,OUTPAT REV HCPCS COMBO 1, 173.75,OTHER, 109.36, 249.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17843,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 121.38,,OUTPAT REV HCPCS COMBO 1, 180.83,OTHER, 115.60, 263.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17844,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 143.26,,OUTPAT REV HCPCS COMBO 1, 204.49,OTHER, 136.43, 310.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17845,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 69.19,,OUTPAT REV HCPCS COMBO 1, 108.91,OTHER, 65.89, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17846,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 54.50,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17847,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 54.50,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17848,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 54.50,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17849,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.14,,OUTPAT REV HCPCS COMBO 1, 44.69,OTHER, 31.56, 71.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17850,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 57.63,,OUTPAT REV HCPCS COMBO 1, 78.22,OTHER, 54.89, 125.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17851,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 57.63,,OUTPAT REV HCPCS COMBO 1, 78.22,OTHER, 54.89, 125.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17852,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 40.01,,OUTPAT REV HCPCS COMBO 1, 59.17,OTHER, 38.11, 86.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17853,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 52.37,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17854,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 52.37,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17855,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 52.37,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17856,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17857,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 64.91,,OUTPAT REV HCPCS COMBO 1, 93.12,OTHER, 61.82, 140.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17858,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 54.63,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 52.03, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17859,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 119.67,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 52.03, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17860,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 55.99,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17861,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 55.99,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17862,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 55.99,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17863,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.86,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17864,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 46.96,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17865,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 63.66,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17866,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 46.96,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17867,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 63.66,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17868,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.86,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17869,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.86,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17870,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 135.45,,OUTPAT REV HCPCS COMBO 1, 192.27,OTHER, 129.00, 294.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17871,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17872,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17873,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 109.08,,OUTPAT REV HCPCS COMBO 1, 145.27,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17874,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.16,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17875,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.16,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17876,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 113.81,,OUTPAT REV HCPCS COMBO 1, 161.56,OTHER, 108.39, 247.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17877,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 113.81,,OUTPAT REV HCPCS COMBO 1, 161.56,OTHER, 108.39, 247.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17878,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 178.07,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17879,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 178.07,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17880,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 221.82,,OUTPAT REV HCPCS COMBO 1, 314.88,OTHER, 211.26, 481.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17881,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 221.82,,OUTPAT REV HCPCS COMBO 1, 314.88,OTHER, 211.26, 481.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17882,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 21.49,,OUTPAT REV HCPCS COMBO 1, 30.51,OTHER, 20.47, 46.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17883,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 46.82,,OUTPAT REV HCPCS COMBO 1, 66.46,OTHER, 44.59, 101.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17884,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 46.82,,OUTPAT REV HCPCS COMBO 1, 66.46,OTHER, 44.59, 101.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17885,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 78.29,,OUTPAT REV HCPCS COMBO 1, 111.13,OTHER, 74.56, 169.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17886,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 78.29,,OUTPAT REV HCPCS COMBO 1, 111.13,OTHER, 74.56, 169.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17887,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 115.52,,OUTPAT REV HCPCS COMBO 1, 163.98,OTHER, 110.02, 250.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17888,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 115.52,,OUTPAT REV HCPCS COMBO 1, 163.98,OTHER, 110.02, 250.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17889,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 154.66,,OUTPAT REV HCPCS COMBO 1, 219.55,OTHER, 147.30, 335.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17890,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 154.66,,OUTPAT REV HCPCS COMBO 1, 219.55,OTHER, 147.30, 335.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17891,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17892,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17893,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17894,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17895,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17896,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 121.42,,OUTPAT REV HCPCS COMBO 1, 149.74,OTHER, 77.35, 263.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17897,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 121.42,,OUTPAT REV HCPCS COMBO 1, 149.74,OTHER, 77.35, 263.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17898,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17899,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17900,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 187.82,,OUTPAT REV HCPCS COMBO 1, 233.57,OTHER, 127.82, 407.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17901,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 187.82,,OUTPAT REV HCPCS COMBO 1, 233.57,OTHER, 127.82, 407.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17902,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17903,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17904,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 296.79,,OUTPAT REV HCPCS COMBO 1, 369.55,OTHER, 203.96, 644.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17905,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 296.79,,OUTPAT REV HCPCS COMBO 1, 369.55,OTHER, 203.96, 644.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17906,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17907,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17908,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 465.53,,OUTPAT REV HCPCS COMBO 1, 580.80,OTHER, 324.71, 1010.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17909,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 465.53,,OUTPAT REV HCPCS COMBO 1, 580.80,OTHER, 324.71, 1010.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17910,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17911,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17912,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 776.48,,OUTPAT REV HCPCS COMBO 1, 954.02,OTHER, 479.76, 1685.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17913,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 776.48,,OUTPAT REV HCPCS COMBO 1, 954.02,OTHER, 479.76, 1685.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17914,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 17915,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1241.98,,OUTPAT REV HCPCS COMBO 1, 1514.86,OTHER, 720.78, 2695.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17916,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 455.30,,OUTPAT REV HCPCS COMBO 1, 646.30,OTHER, 433.62, 988.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17917,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 13.55,,OUTPAT REV HCPCS COMBO 1, 19.23,OTHER, 12.90, 29.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17918,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 75.60,,OUTPAT REV HCPCS COMBO 1, 107.32,OTHER, 72.00, 164.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17919,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 75.60,,OUTPAT REV HCPCS COMBO 1, 107.32,OTHER, 72.00, 164.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17920,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 118.97,,OUTPAT REV HCPCS COMBO 1, 167.97,OTHER, 113.31, 258.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17921,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 123.96,,OUTPAT REV HCPCS COMBO 1, 173.37,OTHER, 118.06, 269.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17922,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 129.33,,OUTPAT REV HCPCS COMBO 1, 179.18,OTHER, 123.17, 280.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17923,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 146.22,,OUTPAT REV HCPCS COMBO 1, 197.44,OTHER, 139.26, 317.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17924,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 142.00,,OUTPAT REV HCPCS COMBO 1, 192.88,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17925,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 163.87,,OUTPAT REV HCPCS COMBO 1, 232.62,OTHER, 156.07, 355.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17926,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 178.07,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17927,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 107.07,,OUTPAT REV HCPCS COMBO 1, 155.10,OTHER, 101.97, 232.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17928,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 114.36,,OUTPAT REV HCPCS COMBO 1, 162.99,OTHER, 108.92, 248.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17929,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 124.73,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17930,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 124.73,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17931,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 124.73,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17932,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 127.41,,OUTPAT REV HCPCS COMBO 1, 177.10,OTHER, 121.35, 276.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17933,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 135.86,,OUTPAT REV HCPCS COMBO 1, 192.85,OTHER, 129.39, 294.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17934,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 146.22,,OUTPAT REV HCPCS COMBO 1, 207.56,OTHER, 139.26, 317.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17935,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 39.15,,OUTPAT REV HCPCS COMBO 1, 55.57,OTHER, 37.28, 84.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17936,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.16,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17937,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 31.61,,OUTPAT REV HCPCS COMBO 1, 44.86,OTHER, 30.10, 68.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17938,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 120.12,,OUTPAT REV HCPCS COMBO 1, 170.52,OTHER, 114.40, 260.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17939,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 23.88,,OUTPAT REV HCPCS COMBO 1, 33.14,OTHER, 22.74, 51.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17940,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 29.55,,OUTPAT REV HCPCS COMBO 1, 39.28,OTHER, 28.14, 64.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17941,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 42.61,,OUTPAT REV HCPCS COMBO 1, 60.49,OTHER, 40.58, 92.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17942,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 9.93,,OUTPAT REV HCPCS COMBO 1, 14.10,OTHER, 9.46, 21.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17943,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 9.93,,OUTPAT REV HCPCS COMBO 1, 54.72,OTHER, 9.46, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17944,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 67.16,,OUTPAT REV HCPCS COMBO 1, 54.72,OTHER, 9.46, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17945,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 115.13,,OUTPAT REV HCPCS COMBO 1, 148.65,OTHER, 101.33, 249.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17946,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 124.16,,OUTPAT REV HCPCS COMBO 1, 166.04,OTHER, 118.25, 269.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17947,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 5.76,,OUTPAT REV HCPCS COMBO 1, 8.17,OTHER, 5.48, 12.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17948,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 5.76,,OUTPAT REV HCPCS COMBO 1, 8.17,OTHER, 5.48, 12.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17949,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 173.83,,OUTPAT REV HCPCS COMBO 1, 350.13,OTHER, 165.55, 680.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17950,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 173.83,,OUTPAT REV HCPCS COMBO 1, 350.13,OTHER, 165.55, 680.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17951,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 274.06,,OUTPAT REV HCPCS COMBO 1, 553.11,OTHER, 261.01, 1078.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17952,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 274.06,,OUTPAT REV HCPCS COMBO 1, 553.11,OTHER, 261.01, 1078.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17953,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 160.28,,OUTPAT REV HCPCS COMBO 1, 308.45,OTHER, 152.65, 567.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17954,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 160.28,,OUTPAT REV HCPCS COMBO 1, 308.45,OTHER, 152.65, 567.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17955,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 231.17,,OUTPAT REV HCPCS COMBO 1, 466.19,OTHER, 220.16, 907.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17956,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 231.17,,OUTPAT REV HCPCS COMBO 1, 466.19,OTHER, 220.16, 907.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17957,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 396.42,,OUTPAT REV HCPCS COMBO 1, 562.72,OTHER, 377.54, 860.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17958,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 396.42,,OUTPAT REV HCPCS COMBO 1, 562.72,OTHER, 377.54, 860.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17959,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 440.21,,OUTPAT REV HCPCS COMBO 1, 624.89,OTHER, 419.25, 955.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17960,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 440.21,,OUTPAT REV HCPCS COMBO 1, 624.89,OTHER, 419.25, 955.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17961,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 61.40,,OUTPAT REV HCPCS COMBO 1, 87.16,OTHER, 58.48, 133.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17962,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 28.90,,OUTPAT REV HCPCS COMBO 1, 41.02,OTHER, 27.52, 62.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17963,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.86,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17964,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1352.69,,OUTPAT REV HCPCS COMBO 1, 1648.47,OTHER, 779.04, 2936.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17965,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1352.69,,OUTPAT REV HCPCS COMBO 1, 1648.47,OTHER, 779.04, 2936.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17966,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1472.34,,OUTPAT REV HCPCS COMBO 1, 1777.88,OTHER, 779.04, 3195.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17967,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1472.34,,OUTPAT REV HCPCS COMBO 1, 1777.88,OTHER, 779.04, 3195.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17968,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1038.45,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17969,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1038.45,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17970,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1038.45,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17971,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1097.72,OTHER, 508.57, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17972,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1097.72,OTHER, 508.57, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17973,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1162.11,OTHER, 779.04, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17974,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1162.11,OTHER, 779.04, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17975,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 8.64,,OUTPAT REV HCPCS COMBO 1, 9.74,OTHER, 1.66, 18.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17976,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 50.87,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17977,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2.71,,OUTPAT REV HCPCS COMBO 1, 11.82,OTHER, 2.58, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17978,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 40.68,,OUTPAT REV HCPCS COMBO 1, 57.75,OTHER, 38.74, 88.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17979,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 21.11,,OUTPAT REV HCPCS COMBO 1, 29.96,OTHER, 20.10, 45.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17980,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 74.64,,OUTPAT REV HCPCS COMBO 1, 88.75,OTHER, 33.71, 162.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17981,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 46.96,,OUTPAT REV HCPCS COMBO 1, 58.81,OTHER, 33.71, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17982,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 176.54,,OUTPAT REV HCPCS COMBO 1, 250.60,OTHER, 168.13, 383.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17983,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 178.07,,OUTPAT REV HCPCS COMBO 1, 231.89,OTHER, 165.06, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17984,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 178.07,,OUTPAT REV HCPCS COMBO 1, 231.89,OTHER, 165.06, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17985,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 19.19,,OUTPAT REV HCPCS COMBO 1, 35.44,OTHER, 18.28, 61.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17986,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 27.63,,OUTPAT REV HCPCS COMBO 1, 44.57,OTHER, 26.32, 61.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17987,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.70,,OUTPAT REV HCPCS COMBO 1, 43.58,OTHER, 29.24, 66.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17988,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17989,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 117.30,,OUTPAT REV HCPCS COMBO 1, 166.51,OTHER, 111.71, 254.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17990,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 42.34,,OUTPAT REV HCPCS COMBO 1, 60.10,OTHER, 40.32, 91.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17991,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 3.47,,OUTPAT REV HCPCS COMBO 1, 4.92,OTHER, 3.30, 7.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17992,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 3.36,,OUTPAT REV HCPCS COMBO 1, 4.77,OTHER, 3.20, 7.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17993,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 9.17,,OUTPAT REV HCPCS COMBO 1, 13.02,OTHER, 8.74, 19.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17994,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 94.82,,OUTPAT REV HCPCS COMBO 1, 134.59,OTHER, 90.30, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17995,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .96,,OUTPAT REV HCPCS COMBO 1, 1.36,OTHER, .91, 2.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17996,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1.48,,OUTPAT REV HCPCS COMBO 1, 2.10,OTHER, 1.41, 3.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17997,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 18.25,,OUTPAT REV HCPCS COMBO 1, 25.91,OTHER, 17.38, 39.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17998,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 65.52,,OUTPAT REV HCPCS COMBO 1, 93.00,OTHER, 62.40, 142.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 17999,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1.03,,OUTPAT REV HCPCS COMBO 1, 1.46,OTHER, .98, 2.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18000,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .72,,OUTPAT REV HCPCS COMBO 1, 1.03,OTHER, .69, 1.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18001,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 3.63,,OUTPAT REV HCPCS COMBO 1, 5.15,OTHER, 3.46, 7.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18002,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 8.07,,OUTPAT REV HCPCS COMBO 1, 11.46,OTHER, 7.69, 17.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18003,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 3.09,,OUTPAT REV HCPCS COMBO 1, 4.38,OTHER, 2.94, 6.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18004,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1.81,,OUTPAT REV HCPCS COMBO 1, 2.56,OTHER, 1.72, 3.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18005,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 5.27,,OUTPAT REV HCPCS COMBO 1, 7.91,OTHER, 5.02, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18006,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 5.87,,OUTPAT REV HCPCS COMBO 1, 7.91,OTHER, 5.02, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18007,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.85,,OUTPAT REV HCPCS COMBO 1, 43.79,OTHER, 29.38, 66.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18008,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 16.22,,OUTPAT REV HCPCS COMBO 1, 23.02,OTHER, 15.45, 35.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18009,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 4.75,,OUTPAT REV HCPCS COMBO 1, 6.74,OTHER, 4.52, 10.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18010,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 3.67,,OUTPAT REV HCPCS COMBO 1, 5.20,OTHER, 3.49, 7.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18011,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 180.15,,OUTPAT REV HCPCS COMBO 1, 575.18,OTHER, 171.57, 1597.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18012,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 180.15,,OUTPAT REV HCPCS COMBO 1, 690.66,OTHER, 171.57, 2082.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18013,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 180.15,,OUTPAT REV HCPCS COMBO 1, 656.15,OTHER, 171.57, 1937.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18014,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 180.15,,OUTPAT REV HCPCS COMBO 1, 607.70,OTHER, 171.57, 1734.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18015,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 225.30,,OUTPAT REV HCPCS COMBO 1, 735.35,OTHER, 214.57, 2065.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18016,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 386.03,,OUTPAT REV HCPCS COMBO 1, 421.89,OTHER, 18.42, 837.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18017,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2.17,,OUTPAT REV HCPCS COMBO 1, 3.08,OTHER, 2.06, 4.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18018,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18019,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18020,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18021,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18022,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18023,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18024,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18025,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18026,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18027,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18028,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18029,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18030,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 187.37,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18031,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 187.37,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18032,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 187.37,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18033,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 187.37,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18034,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18035,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18036,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18037,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18038,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18039,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18040,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18041,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18042,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18043,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18044,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18045,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18046,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18047,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18048,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18049,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18050,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18051,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18052,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18053,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18054,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.97,,OUTPAT REV HCPCS COMBO 1, 62.01,OTHER, 42.53, 104.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18055,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 51.47,,OUTPAT REV HCPCS COMBO 1, 73.06,OTHER, 49.02, 111.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18056,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18057,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 225.75,,OUTPAT REV HCPCS COMBO 1, 320.46,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18058,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 18.96,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18059,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18060,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 15.80,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18061,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18062,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 12.19,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18063,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18064,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 6.77,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18065,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1.42,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18066,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.86,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18067,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1.42,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18068,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2.04,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18069,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 45.60,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18070,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2.71,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18071,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2.71,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18072,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 83.04,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18073,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2.71,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18074,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 81.27,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18075,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 26.19,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18076,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 26.19,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18077,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 149.97,,OUTPAT REV HCPCS COMBO 1, 212.89,OTHER, 142.83, 325.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18078,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 54.99,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18079,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.86,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18080,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 444.56,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18081,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 323.74,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18082,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 4.06,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18083,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2.71,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18084,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 45.60,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18085,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 45.60,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18086,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 45.60,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18087,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 45.60,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18088,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 45.60,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18089,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 45.60,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18090,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 45.60,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18091,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2.71,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18092,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 45.60,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18093,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 46.05,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18094,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 32.44,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18095,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 32.44,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18096,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 33.86,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18097,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 62.12,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18098,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18099,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 6.77,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18100,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 6.77,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18101,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 6.77,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18102,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 8.13,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18103,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 10.84,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18104,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18105,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 12.88,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18106,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 12.88,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18107,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 13.55,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18108,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 13.55,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18109,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 13.55,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18110,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 13.55,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18111,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18112,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18113,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 20.99,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18114,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 4.52,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18115,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1.42,,OUTPAT REV HCPCS COMBO 1, 2.02,OTHER, 1.35, 3.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18116,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 226.20,,OUTPAT REV HCPCS COMBO 1, 321.10,OTHER, 215.43, 490.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18117,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 258.26,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18118,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18119,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18120,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18121,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18122,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18123,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18124,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18125,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 15.36,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18126,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 68.71,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18127,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 64.40,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18128,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 42.08,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18129,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 38.62,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18130,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 117.52,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18131,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 3433.97,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18132,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 20.42,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18133,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18134,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18135,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18136,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18137,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18138,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18139,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 1083.60,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18140,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18141,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18142,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18143,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18144,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18145,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18146,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 632.10,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18147,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 632.10,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18148,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 632.10,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18149,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18150,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18151,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18152,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18153,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18154,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 30.31,,OUTPAT REV HCPCS COMBO 1, 43.03,OTHER, 28.87, 65.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18155,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 4.52,,OUTPAT REV HCPCS COMBO 1, 6.41,OTHER, 4.30, 9.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18156,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2618.70,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18157,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2167.20,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18158,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2167.20,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18159,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, 2167.20,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18160,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18161,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18162,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18163,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18164,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18165,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18166,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18167,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18168,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18169,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18170,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18171,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18172,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18173,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18174,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18175,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18176,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18177,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18178,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18179,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18180,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18181,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18182,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18183,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18184,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18185,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18186,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18187,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_MOLINA,MOLINA MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18188,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18189,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18190,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18191,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18192,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18193,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18194,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18195,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18196,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18197,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18198,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18199,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18200,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18201,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18202,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18203,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18204,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18205,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18206,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 209.32,,OUTPAT REV HCPCS COMBO 1, 271.70,OTHER, 142.76, 477.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18207,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 209.32,,OUTPAT REV HCPCS COMBO 1, 271.70,OTHER, 142.76, 477.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18208,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 118.79,,OUTPAT REV HCPCS COMBO 1, 168.89,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18209,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18210,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 211.23,,OUTPAT REV HCPCS COMBO 1, 273.87,OTHER, 142.76, 481.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18211,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18212,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 155.70,,OUTPAT REV HCPCS COMBO 1, 242.16,OTHER, 155.70, 354.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18213,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18214,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18215,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18216,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18217,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18218,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18219,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18220,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18221,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18222,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18223,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18224,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18225,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18226,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18227,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18228,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18229,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18230,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18231,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18232,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18233,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18234,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18235,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18236,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18237,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18238,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18239,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18240,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18241,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18242,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18243,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18244,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18245,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18246,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18247,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18248,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18249,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18250,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18251,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18252,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18253,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18254,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18255,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18256,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 145.30,,OUTPAT REV HCPCS COMBO 1, 185.53,OTHER, 86.20, 331.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18257,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18258,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18259,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18260,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18261,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18262,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18263,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 165.01,,OUTPAT REV HCPCS COMBO 1, 278.63,OTHER, 165.01, 383.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18264,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 296.20,,OUTPAT REV HCPCS COMBO 1, 427.61,OTHER, 296.20, 675.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18265,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 179.25,,OUTPAT REV HCPCS COMBO 1, 237.66,OTHER, 143.26, 408.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18266,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 193.33,,OUTPAT REV HCPCS COMBO 1, 253.66,OTHER, 143.26, 440.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18267,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 209.63,,OUTPAT REV HCPCS COMBO 1, 272.17,OTHER, 143.26, 477.75,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18268,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 191.34,,OUTPAT REV HCPCS COMBO 1, 251.39,OTHER, 143.26, 436.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18269,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18270,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 202.93,,OUTPAT REV HCPCS COMBO 1, 264.56,OTHER, 143.26, 462.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18271,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 204.98,,OUTPAT REV HCPCS COMBO 1, 306.35,OTHER, 204.98, 467.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18272,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18273,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18274,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 230.23,,OUTPAT REV HCPCS COMBO 1, 293.08,OTHER, 132.82, 524.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18275,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 836.72,,OUTPAT REV HCPCS COMBO 1, 1023.77,OTHER, 309.01, 1906.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18276,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18277,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1408.79,,OUTPAT REV HCPCS COMBO 1, 1703.49,OTHER, 435.32, 3210.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18278,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18279,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18280,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18281,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18282,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 145.30,,OUTPAT REV HCPCS COMBO 1, 200.99,OTHER, 145.30, 331.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18283,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18284,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18285,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18286,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18287,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18288,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18289,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18290,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 57.02,,OUTPAT REV HCPCS COMBO 1, 124.43,OTHER, 57.02, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18291,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 53.32,,OUTPAT REV HCPCS COMBO 1, 120.23,OTHER, 53.32, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18292,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 62.14,,OUTPAT REV HCPCS COMBO 1, 130.25,OTHER, 62.14, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18293,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 62.14,,OUTPAT REV HCPCS COMBO 1, 130.25,OTHER, 62.14, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18294,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18295,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18296,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 339.79,,OUTPAT REV HCPCS COMBO 1, 424.57,OTHER, 162.56, 774.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18297,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 260.82,,OUTPAT REV HCPCS COMBO 1, 334.89,OTHER, 162.56, 594.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18298,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 496.58,,OUTPAT REV HCPCS COMBO 1, 675.88,OTHER, 470.23, 1131.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18299,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 406.01,,OUTPAT REV HCPCS COMBO 1, 499.77,OTHER, 162.56, 925.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18300,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 406.01,,OUTPAT REV HCPCS COMBO 1, 499.77,OTHER, 162.56, 925.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18301,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 148.80,,OUTPAT REV HCPCS COMBO 1, 207.69,OTHER, 148.80, 339.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18302,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 148.80,,OUTPAT REV HCPCS COMBO 1, 207.69,OTHER, 148.80, 339.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18303,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 133.93,,OUTPAT REV HCPCS COMBO 1, 176.70,OTHER, 103.34, 305.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18304,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 485.88,,OUTPAT REV HCPCS COMBO 1, 596.69,OTHER, 188.66, 1107.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18305,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 485.88,,OUTPAT REV HCPCS COMBO 1, 596.69,OTHER, 188.66, 1107.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18306,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 845.35,,OUTPAT REV HCPCS COMBO 1, 1089.64,OTHER, 544.52, 1926.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18307,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 15.05,,OUTPAT REV HCPCS COMBO 1, 22.43,OTHER, 15.05, 34.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18308,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18309,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18310,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18311,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18312,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18313,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18314,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 16.02,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18315,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 440.37,,OUTPAT REV HCPCS COMBO 1, 579.04,OTHER, 331.58, 1003.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18316,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18317,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18318,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18319,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18320,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18321,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 124.21,OTHER, 26.22, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18322,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 124.21,OTHER, 26.22, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18323,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18324,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18325,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18326,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18327,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18328,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18329,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18330,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18331,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18332,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18333,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18334,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18335,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 501.48,,OUTPAT REV HCPCS COMBO 1, 718.33,OTHER, 501.48, 1142.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18336,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18337,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18338,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18339,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18340,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18341,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18342,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18343,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18344,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18345,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18346,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18347,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18348,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18349,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18350,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18351,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18352,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18353,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18354,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18355,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18356,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18357,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18358,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18359,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18360,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18361,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 173.27,,OUTPAT REV HCPCS COMBO 1, 242.39,OTHER, 173.27, 394.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18362,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 173.27,,OUTPAT REV HCPCS COMBO 1, 242.39,OTHER, 173.27, 394.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18363,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18364,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 96.75,,OUTPAT REV HCPCS COMBO 1, 199.77,OTHER, 96.75, 377.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18365,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 96.75,,OUTPAT REV HCPCS COMBO 1, 266.50,OTHER, 96.75, 657.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18366,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1478.34,,OUTPAT REV HCPCS COMBO 1, 2146.91,OTHER, 1478.34, 3369.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18367,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1478.34,,OUTPAT REV HCPCS COMBO 1, 2146.91,OTHER, 1478.34, 3369.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18368,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 482.83,,OUTPAT REV HCPCS COMBO 1, 719.65,OTHER, 482.83, 1100.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18369,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 863.68,,OUTPAT REV HCPCS COMBO 1, 1287.31,OTHER, 863.68, 1968.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18370,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 195.18,,OUTPAT REV HCPCS COMBO 1, 290.91,OTHER, 195.18, 444.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18371,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18372,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 112.28,,OUTPAT REV HCPCS COMBO 1, 162.43,OTHER, 112.28, 255.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18373,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 97.21,,OUTPAT REV HCPCS COMBO 1, 145.32,OTHER, 97.21, 221.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18374,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 62.09,,OUTPAT REV HCPCS COMBO 1, 116.13,OTHER, 62.09, 191.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18375,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 76.24,OTHER, 51.17, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18376,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 91.62,,OUTPAT REV HCPCS COMBO 1, 124.60,OTHER, 86.34, 208.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18377,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18378,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18379,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18380,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 58.91,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18381,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18382,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 161.46,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18383,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18384,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18385,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18386,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 122.45,,OUTPAT REV HCPCS COMBO 1, 171.96,OTHER, 122.45, 279.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18387,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18388,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 94.39,,OUTPAT REV HCPCS COMBO 1, 127.74,OTHER, 86.34, 215.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18389,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18390,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 137.97,,OUTPAT REV HCPCS COMBO 1, 189.58,OTHER, 137.97, 314.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18391,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18392,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 84.85,,OUTPAT REV HCPCS COMBO 1, 116.92,OTHER, 84.85, 193.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18393,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18394,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 234.79,,OUTPAT REV HCPCS COMBO 1, 299.54,OTHER, 138.19, 535.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18395,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18396,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 165.67,,OUTPAT REV HCPCS COMBO 1, 221.04,OTHER, 138.19, 377.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18397,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18398,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 127.28,,OUTPAT REV HCPCS COMBO 1, 177.44,OTHER, 127.28, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18399,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18400,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 44.60,,OUTPAT REV HCPCS COMBO 1, 71.21,OTHER, 44.60, 101.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18401,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18402,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 152.34,,OUTPAT REV HCPCS COMBO 1, 193.56,OTHER, 86.34, 347.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18403,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18404,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 178.71,,OUTPAT REV HCPCS COMBO 1, 223.50,OTHER, 86.34, 407.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18405,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1259.10,,OUTPAT REV HCPCS COMBO 1, 1313.91,OTHER, 283.82, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18406,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 935.89,,OUTPAT REV HCPCS COMBO 1, 1313.91,OTHER, 283.82, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18407,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18408,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18409,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 962.60,,OUTPAT REV HCPCS COMBO 1, 1196.04,OTHER, 432.18, 2193.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18410,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 962.60,,OUTPAT REV HCPCS COMBO 1, 1196.04,OTHER, 432.18, 2193.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18411,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18412,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18413,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1259.10,,OUTPAT REV HCPCS COMBO 1, 1545.39,OTHER, 485.27, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18414,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1259.10,,OUTPAT REV HCPCS COMBO 1, 1545.39,OTHER, 485.27, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18415,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18416,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18417,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 781.62,,OUTPAT REV HCPCS COMBO 1, 955.20,OTHER, 283.82, 1781.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18418,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18419,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 518.18,,OUTPAT REV HCPCS COMBO 1, 691.35,OTHER, 432.18, 1180.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18420,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18421,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 679.40,,OUTPAT REV HCPCS COMBO 1, 887.08,OTHER, 485.27, 1548.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18422,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18423,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 734.01,,OUTPAT REV HCPCS COMBO 1, 901.22,OTHER, 283.82, 1673.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18424,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 734.17,,OUTPAT REV HCPCS COMBO 1, 901.22,OTHER, 283.82, 1673.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18425,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18426,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18427,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 839.22,,OUTPAT REV HCPCS COMBO 1, 1055.93,OTHER, 432.18, 1912.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18428,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1056.51,,OUTPAT REV HCPCS COMBO 1, 1302.68,OTHER, 432.18, 2407.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18429,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18430,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18431,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 350.02,,OUTPAT REV HCPCS COMBO 1, 513.03,OTHER, 350.02, 797.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18432,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18433,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1076.96,,OUTPAT REV HCPCS COMBO 1, 1290.59,OTHER, 283.82, 2454.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18434,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18435,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1120.02,,OUTPAT REV HCPCS COMBO 1, 1374.81,OTHER, 432.18, 2552.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18436,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18437,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1013.04,,OUTPAT REV HCPCS COMBO 1, 1265.96,OTHER, 485.27, 2308.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18438,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18439,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 843.77,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18440,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 843.77,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18441,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 843.77,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18442,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18443,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18444,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18445,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1015.19,,OUTPAT REV HCPCS COMBO 1, 1270.81,OTHER, 495.38, 2313.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18446,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18447,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1317.38,,OUTPAT REV HCPCS COMBO 1, 1681.52,OTHER, 779.04, 3002.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18448,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18449,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 971.97,,OUTPAT REV HCPCS COMBO 1, 1224.87,OTHER, 508.57, 2215.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18450,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18451,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1036.73,,OUTPAT REV HCPCS COMBO 1, 1324.21,OTHER, 616.91, 2362.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18452,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18453,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1186.59,,OUTPAT REV HCPCS COMBO 1, 1532.99,OTHER, 779.04, 2704.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18454,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18455,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 979.65,,OUTPAT REV HCPCS COMBO 1, 1233.59,OTHER, 508.57, 2232.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18456,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18457,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 976.96,,OUTPAT REV HCPCS COMBO 1, 1256.33,OTHER, 616.91, 2226.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18458,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18459,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1123.27,,OUTPAT REV HCPCS COMBO 1, 1461.09,OTHER, 779.04, 2560.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18460,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18461,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1138.21,,OUTPAT REV HCPCS COMBO 1, 1413.66,OTHER, 508.57, 2594.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18462,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18463,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1757.38,,OUTPAT REV HCPCS COMBO 1, 2181.19,OTHER, 779.04, 4005.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18464,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1757.38,,OUTPAT REV HCPCS COMBO 1, 2181.19,OTHER, 779.04, 4005.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18465,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18466,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18467,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18468,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18469,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18470,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18471,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18472,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18473,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18474,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18475,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18476,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18477,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18478,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18479,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18480,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18481,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 195.04,,OUTPAT REV HCPCS COMBO 1, 242.05,OTHER, 86.34, 444.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18482,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 196.33,,OUTPAT REV HCPCS COMBO 1, 243.52,OTHER, 86.34, 447.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18483,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18484,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18485,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 159.59,,OUTPAT REV HCPCS COMBO 1, 214.14,OTHER, 138.19, 363.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18486,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 182.39,,OUTPAT REV HCPCS COMBO 1, 240.03,OTHER, 138.19, 415.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18487,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18488,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18489,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 190.18,,OUTPAT REV HCPCS COMBO 1, 248.87,OTHER, 138.19, 433.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18490,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18491,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 127.28,,OUTPAT REV HCPCS COMBO 1, 165.10,OTHER, 86.34, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18492,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18493,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18494,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18495,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18496,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18497,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18498,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18499,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18500,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1356.87,OTHER, 432.18, 2737.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18501,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1201.21,,OUTPAT REV HCPCS COMBO 1, 1356.87,OTHER, 432.18, 2737.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18502,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18503,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1498.49,,OUTPAT REV HCPCS COMBO 1, 1817.25,OTHER, 485.27, 3415.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18504,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18505,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18506,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18507,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18508,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18509,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18510,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18511,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2141.41,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18512,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18513,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18514,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18515,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18516,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18517,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18518,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18519,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18520,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 544.38,,OUTPAT REV HCPCS COMBO 1, 1310.99,OTHER, 544.38, 2768.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18521,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1214.75,,OUTPAT REV HCPCS COMBO 1, 1310.99,OTHER, 544.38, 2768.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18522,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18523,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18524,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 130.72,,OUTPAT REV HCPCS COMBO 1, 169.01,OTHER, 86.34, 297.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18525,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 130.72,,OUTPAT REV HCPCS COMBO 1, 169.01,OTHER, 86.34, 297.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18526,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18527,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18528,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 189.11,,OUTPAT REV HCPCS COMBO 1, 247.65,OTHER, 138.19, 430.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18529,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18530,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 279.76,,OUTPAT REV HCPCS COMBO 1, 350.60,OTHER, 138.19, 637.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18531,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18532,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 307.96,,OUTPAT REV HCPCS COMBO 1, 382.63,OTHER, 138.19, 701.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18533,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18534,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 229.47,,OUTPAT REV HCPCS COMBO 1, 293.50,OTHER, 138.19, 522.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18535,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18536,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 205.14,,OUTPAT REV HCPCS COMBO 1, 265.86,OTHER, 138.19, 467.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18537,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18538,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 161.46,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18539,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18540,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 107.50,,OUTPAT REV HCPCS COMBO 1, 142.64,OTHER, 86.34, 245.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18541,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18542,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.06,OTHER, 36.98, 88.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18543,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 163.44,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18544,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18545,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 199.31,,OUTPAT REV HCPCS COMBO 1, 259.24,OTHER, 138.19, 454.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18546,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18547,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 118.00,,OUTPAT REV HCPCS COMBO 1, 166.91,OTHER, 118.00, 268.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18548,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18549,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 329.50,,OUTPAT REV HCPCS COMBO 1, 407.08,OTHER, 138.19, 750.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18550,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18551,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1225.59,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18552,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1225.59,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18553,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1225.59,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18554,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18555,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18556,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18557,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 483.75,,OUTPAT REV HCPCS COMBO 1, 664.89,OTHER, 483.75, 1102.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18558,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18559,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1392.67,,OUTPAT REV HCPCS COMBO 1, 1649.11,OTHER, 283.82, 3173.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18560,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1392.67,,OUTPAT REV HCPCS COMBO 1, 1649.11,OTHER, 283.82, 3173.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18561,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18562,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18563,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1376.00,,OUTPAT REV HCPCS COMBO 1, 1665.51,OTHER, 432.18, 3136.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18564,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18565,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1207.81,,OUTPAT REV HCPCS COMBO 1, 1439.18,OTHER, 283.82, 2752.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18566,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18567,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1364.62,,OUTPAT REV HCPCS COMBO 1, 1652.58,OTHER, 432.18, 3110.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18568,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18569,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1290.00,,OUTPAT REV HCPCS COMBO 1, 1580.48,OTHER, 485.27, 2940.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18570,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18571,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1401.19,,OUTPAT REV HCPCS COMBO 1, 1712.29,OTHER, 508.57, 3193.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18572,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18573,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1561.88,,OUTPAT REV HCPCS COMBO 1, 1894.78,OTHER, 508.57, 3559.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18574,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18575,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1370.93,,OUTPAT REV HCPCS COMBO 1, 1677.93,OTHER, 508.57, 3124.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18576,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18577,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1703.32,,OUTPAT REV HCPCS COMBO 1, 2119.80,OTHER, 779.04, 3881.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18578,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18579,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2072.93,,OUTPAT REV HCPCS COMBO 1, 2539.54,OTHER, 779.04, 4724.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18580,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18581,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1941.42,,OUTPAT REV HCPCS COMBO 1, 2390.20,OTHER, 779.04, 4424.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18582,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18583,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18584,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18585,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18586,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 179.56,,OUTPAT REV HCPCS COMBO 1, 236.81,OTHER, 138.19, 409.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18587,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18588,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 141.74,,OUTPAT REV HCPCS COMBO 1, 193.87,OTHER, 138.19, 323.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18589,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18590,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1051.04,,OUTPAT REV HCPCS COMBO 1, 1261.16,OTHER, 283.82, 2395.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18591,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1051.04,,OUTPAT REV HCPCS COMBO 1, 1261.16,OTHER, 283.82, 2395.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18592,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18593,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18594,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1015.49,,OUTPAT REV HCPCS COMBO 1, 1256.10,OTHER, 432.18, 2314.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18595,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18596,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 686.07,,OUTPAT REV HCPCS COMBO 1, 894.65,OTHER, 485.27, 1563.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18597,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18598,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1435.73,,OUTPAT REV HCPCS COMBO 1, 1751.53,OTHER, 508.57, 3272.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18599,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18600,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2152.02,,OUTPAT REV HCPCS COMBO 1, 2629.35,OTHER, 779.04, 4904.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18601,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18602,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18603,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18604,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18605,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18606,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18607,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18608,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 126.48,,OUTPAT REV HCPCS COMBO 1, 164.19,OTHER, 86.34, 288.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18609,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18610,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 179.46,,OUTPAT REV HCPCS COMBO 1, 224.35,OTHER, 86.34, 408.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18611,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18612,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 165.68,,OUTPAT REV HCPCS COMBO 1, 208.71,OTHER, 86.34, 377.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18613,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 165.68,,OUTPAT REV HCPCS COMBO 1, 208.71,OTHER, 86.34, 377.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18614,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 171.85,,OUTPAT REV HCPCS COMBO 1, 215.71,OTHER, 86.34, 391.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18615,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18616,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18617,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18618,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18619,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18620,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18621,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18622,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18623,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18624,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 136.74,,OUTPAT REV HCPCS COMBO 1, 175.84,OTHER, 86.34, 311.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18625,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 130.77,,OUTPAT REV HCPCS COMBO 1, 169.06,OTHER, 86.34, 298.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18626,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 130.77,,OUTPAT REV HCPCS COMBO 1, 169.06,OTHER, 86.34, 298.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18627,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18628,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18629,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18630,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 178.02,,OUTPAT REV HCPCS COMBO 1, 235.06,OTHER, 138.19, 405.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18631,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 178.02,,OUTPAT REV HCPCS COMBO 1, 235.06,OTHER, 138.19, 405.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18632,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 182.68,,OUTPAT REV HCPCS COMBO 1, 240.36,OTHER, 138.19, 416.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18633,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18634,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18635,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18636,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 175.36,,OUTPAT REV HCPCS COMBO 1, 219.70,OTHER, 86.34, 399.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18637,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 170.74,,OUTPAT REV HCPCS COMBO 1, 214.45,OTHER, 86.34, 389.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18638,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 170.74,,OUTPAT REV HCPCS COMBO 1, 214.45,OTHER, 86.34, 389.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18639,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18640,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18641,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18642,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 163.79,,OUTPAT REV HCPCS COMBO 1, 206.56,OTHER, 86.34, 373.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18643,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 168.41,,OUTPAT REV HCPCS COMBO 1, 211.81,OTHER, 86.34, 383.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18644,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 163.79,,OUTPAT REV HCPCS COMBO 1, 206.56,OTHER, 86.34, 373.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18645,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18646,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18647,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18648,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 184.47,,OUTPAT REV HCPCS COMBO 1, 230.04,OTHER, 86.34, 420.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18649,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 178.71,,OUTPAT REV HCPCS COMBO 1, 223.50,OTHER, 86.34, 407.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18650,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18651,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18652,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18653,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 185.16,,OUTPAT REV HCPCS COMBO 1, 230.83,OTHER, 86.34, 421.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18654,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 185.16,,OUTPAT REV HCPCS COMBO 1, 230.83,OTHER, 86.34, 421.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18655,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 190.92,,OUTPAT REV HCPCS COMBO 1, 237.37,OTHER, 86.34, 435.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18656,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18657,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18658,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18659,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 58.91,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18660,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 81.70,,OUTPAT REV HCPCS COMBO 1, 125.68,OTHER, 81.70, 186.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18661,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 58.91,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18662,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18663,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18664,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18665,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 170.11,,OUTPAT REV HCPCS COMBO 1, 213.73,OTHER, 86.34, 387.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18666,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 164.82,,OUTPAT REV HCPCS COMBO 1, 207.73,OTHER, 86.34, 375.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18667,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 164.83,,OUTPAT REV HCPCS COMBO 1, 207.74,OTHER, 86.34, 375.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18668,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18669,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18670,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18671,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 191.64,,OUTPAT REV HCPCS COMBO 1, 238.18,OTHER, 86.34, 436.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18672,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 196.26,,OUTPAT REV HCPCS COMBO 1, 243.44,OTHER, 86.34, 447.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18673,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 191.64,,OUTPAT REV HCPCS COMBO 1, 238.18,OTHER, 86.34, 436.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18674,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18675,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18676,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18677,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 181.03,,OUTPAT REV HCPCS COMBO 1, 238.48,OTHER, 138.19, 412.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18678,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 175.27,,OUTPAT REV HCPCS COMBO 1, 231.94,OTHER, 138.19, 399.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18679,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 175.27,,OUTPAT REV HCPCS COMBO 1, 231.94,OTHER, 138.19, 399.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18680,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18681,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18682,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18683,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 175.94,,OUTPAT REV HCPCS COMBO 1, 220.36,OTHER, 86.34, 400.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18684,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 175.99,,OUTPAT REV HCPCS COMBO 1, 220.42,OTHER, 86.34, 401.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18685,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 180.62,,OUTPAT REV HCPCS COMBO 1, 225.67,OTHER, 86.34, 411.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18686,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18687,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18688,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18689,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 146.59,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18690,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 135.73,,OUTPAT REV HCPCS COMBO 1, 174.69,OTHER, 86.34, 309.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18691,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18692,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18693,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18694,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18695,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18696,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18697,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18698,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18699,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18700,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18701,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18702,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18703,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18704,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18705,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18706,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18707,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18708,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18709,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18710,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18711,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18712,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18713,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18714,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18715,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 813.42,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18716,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 1061.06,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18717,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18718,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18719,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18720,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18721,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18722,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 287.67,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18723,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 287.67,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18724,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18725,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18726,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 287.67,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18727,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18728,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18729,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 813.42,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18730,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18731,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18732,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18733,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18734,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18735,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18736,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18737,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18738,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18739,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18740,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18741,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18742,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18743,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18744,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1216.47,,OUTPAT REV HCPCS COMBO 1, 1484.34,OTHER, 432.18, 2772.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18745,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1216.47,,OUTPAT REV HCPCS COMBO 1, 1484.34,OTHER, 432.18, 2772.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18746,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18747,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18748,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18749,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18750,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18751,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18752,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18753,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 822.87,,OUTPAT REV HCPCS COMBO 1, 1055.55,OTHER, 508.57, 1875.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18754,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18755,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1419.11,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18756,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1419.11,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18757,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1419.11,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18758,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18759,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18760,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18761,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18762,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18763,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18764,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18765,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18766,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18767,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18768,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18769,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18770,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18771,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18772,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18773,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18774,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18775,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18776,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18777,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18778,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18779,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18780,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18781,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18782,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18783,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18784,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18785,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18786,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18787,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18788,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18789,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18790,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18791,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18792,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18793,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1113.81,,OUTPAT REV HCPCS COMBO 1, 1450.34,OTHER, 779.04, 2538.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18794,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1113.81,,OUTPAT REV HCPCS COMBO 1, 1450.34,OTHER, 779.04, 2538.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18795,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18796,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18797,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18798,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18799,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18800,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18801,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 154.92,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18802,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 154.92,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18803,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 154.92,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18804,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18805,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18806,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18807,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18808,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18809,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18810,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18811,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18812,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18813,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18814,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18815,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18816,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 195.73,,OUTPAT REV HCPCS COMBO 1, 234.40,OTHER, 146.51, 446.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18817,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 155.65,,OUTPAT REV HCPCS COMBO 1, 234.40,OTHER, 146.51, 446.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18818,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18819,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18820,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 160.19,,OUTPAT REV HCPCS COMBO 1, 202.98,OTHER, 88.46, 365.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18821,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 160.19,,OUTPAT REV HCPCS COMBO 1, 202.98,OTHER, 88.46, 365.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18822,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 164.81,,OUTPAT REV HCPCS COMBO 1, 208.23,OTHER, 88.46, 375.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18823,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18824,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18825,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18826,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 167.46,,OUTPAT REV HCPCS COMBO 1, 210.73,OTHER, 86.34, 381.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18827,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 162.18,,OUTPAT REV HCPCS COMBO 1, 204.73,OTHER, 86.34, 369.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18828,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 162.18,,OUTPAT REV HCPCS COMBO 1, 204.73,OTHER, 86.34, 369.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18829,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18830,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18831,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18832,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 208.05,,OUTPAT REV HCPCS COMBO 1, 269.16,OTHER, 138.19, 474.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18833,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 212.67,,OUTPAT REV HCPCS COMBO 1, 274.41,OTHER, 138.19, 484.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18834,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 208.05,,OUTPAT REV HCPCS COMBO 1, 269.16,OTHER, 138.19, 474.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18835,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18836,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18837,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18838,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 325.08,,OUTPAT REV HCPCS COMBO 1, 402.07,OTHER, 138.19, 740.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18839,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 319.17,,OUTPAT REV HCPCS COMBO 1, 395.36,OTHER, 138.19, 727.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18840,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 319.17,,OUTPAT REV HCPCS COMBO 1, 395.36,OTHER, 138.19, 727.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18841,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18842,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18843,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18844,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 116.95,,OUTPAT REV HCPCS COMBO 1, 153.37,OTHER, 86.34, 266.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18845,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18846,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 195.94,,OUTPAT REV HCPCS COMBO 1, 243.07,OTHER, 86.34, 446.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18847,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 191.32,,OUTPAT REV HCPCS COMBO 1, 237.82,OTHER, 86.34, 436.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18848,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 191.32,,OUTPAT REV HCPCS COMBO 1, 237.82,OTHER, 86.34, 436.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18849,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18850,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18851,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18852,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 74.90,OTHER, 36.98, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18853,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 74.90,OTHER, 36.98, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18854,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 73.96,,OUTPAT REV HCPCS COMBO 1, 116.89,OTHER, 73.96, 168.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18855,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18856,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18857,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18858,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 163.83,,OUTPAT REV HCPCS COMBO 1, 218.95,OTHER, 138.19, 373.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18859,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 163.83,,OUTPAT REV HCPCS COMBO 1, 218.95,OTHER, 138.19, 373.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18860,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 169.42,,OUTPAT REV HCPCS COMBO 1, 225.30,OTHER, 138.19, 386.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18861,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18862,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18863,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18864,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 185.33,,OUTPAT REV HCPCS COMBO 1, 243.37,OTHER, 138.19, 422.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18865,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 179.52,,OUTPAT REV HCPCS COMBO 1, 236.76,OTHER, 138.19, 409.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18866,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 179.52,,OUTPAT REV HCPCS COMBO 1, 236.76,OTHER, 138.19, 409.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18867,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18868,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18869,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18870,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 146.18,,OUTPAT REV HCPCS COMBO 1, 186.56,OTHER, 86.34, 333.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18871,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 146.18,,OUTPAT REV HCPCS COMBO 1, 186.56,OTHER, 86.34, 333.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18872,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18873,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18874,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 202.21,,OUTPAT REV HCPCS COMBO 1, 250.19,OTHER, 86.34, 460.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18875,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 197.50,,OUTPAT REV HCPCS COMBO 1, 244.84,OTHER, 86.34, 450.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18876,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 197.59,,OUTPAT REV HCPCS COMBO 1, 244.94,OTHER, 86.34, 450.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18877,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18878,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18879,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18880,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 100.19,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18881,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 100.19,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18882,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 100.19,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18883,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18884,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18885,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18886,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18887,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18888,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18889,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18890,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18891,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18892,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18893,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18894,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 139.75,,OUTPAT REV HCPCS COMBO 1, 179.26,OTHER, 86.34, 318.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18895,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18896,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18897,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18898,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18899,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18900,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18901,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18902,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18903,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18904,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18905,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18906,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18907,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18908,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18909,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18910,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18911,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 991.15,,OUTPAT REV HCPCS COMBO 1, 1193.14,OTHER, 283.82, 2258.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18912,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18913,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18914,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18915,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18916,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18917,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18918,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18919,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18920,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18921,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18922,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18923,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18924,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18925,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18926,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18927,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18928,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18929,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18930,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18931,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18932,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18933,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18934,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18935,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18936,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1173.04,,OUTPAT REV HCPCS COMBO 1, 1435.02,OTHER, 432.18, 2673.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18937,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1167.20,,OUTPAT REV HCPCS COMBO 1, 1428.39,OTHER, 432.18, 2660.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18938,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1167.20,,OUTPAT REV HCPCS COMBO 1, 1428.39,OTHER, 432.18, 2660.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18939,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18940,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18941,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18942,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18943,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18944,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18945,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18946,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18947,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18948,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 597.27,,OUTPAT REV HCPCS COMBO 1, 796.22,OTHER, 495.38, 1361.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18949,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 597.27,,OUTPAT REV HCPCS COMBO 1, 796.22,OTHER, 495.38, 1361.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18950,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18951,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18952,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18953,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18954,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18955,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18956,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18957,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18958,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18959,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18960,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18961,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18962,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18963,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18964,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1556.76,,OUTPAT REV HCPCS COMBO 1, 1953.37,OTHER, 779.04, 3547.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18965,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1556.76,,OUTPAT REV HCPCS COMBO 1, 1953.37,OTHER, 779.04, 3547.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18966,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18967,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18968,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18969,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18970,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1356.11,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18971,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1356.11,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18972,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18973,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18974,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18975,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18976,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18977,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18978,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18979,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18980,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18981,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18982,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18983,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18984,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18985,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18986,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18987,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18988,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18989,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18990,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18991,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18992,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18993,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18994,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18995,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18996,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18997,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 18998,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1227.35,OTHER, 786.90, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 18999,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1323.48,OTHER, 786.90, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19000,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1474.10,OTHER, 989.00, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19001,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 786.90,,OUTPAT REV HCPCS COMBO 1, 1227.35,OTHER, 786.90, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19002,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 786.90,,OUTPAT REV HCPCS COMBO 1, 1323.48,OTHER, 786.90, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19003,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19004,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19005,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19006,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19007,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19008,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 71.38,,OUTPAT REV HCPCS COMBO 1, 102.58,OTHER, 71.38, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19009,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 71.38,,OUTPAT REV HCPCS COMBO 1, 102.58,OTHER, 71.38, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19010,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19011,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19012,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 83.13,OTHER, 36.98, 172.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19013,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19014,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 254.96,,OUTPAT REV HCPCS COMBO 1, 322.43,OTHER, 138.19, 581.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19015,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 254.96,,OUTPAT REV HCPCS COMBO 1, 322.43,OTHER, 138.19, 581.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19016,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19017,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19018,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1125.78,,OUTPAT REV HCPCS COMBO 1, 1346.03,OTHER, 283.82, 2565.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19019,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19020,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1269.20,,OUTPAT REV HCPCS COMBO 1, 1544.22,OTHER, 432.18, 2892.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19021,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19022,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1433.28,,OUTPAT REV HCPCS COMBO 1, 1743.20,OTHER, 485.27, 3266.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19023,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19024,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2571.41,,OUTPAT REV HCPCS COMBO 1, 3113.75,OTHER, 813.20, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19025,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19026,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1431.39,,OUTPAT REV HCPCS COMBO 1, 1743.46,OTHER, 495.38, 3262.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19027,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19028,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2239.96,,OUTPAT REV HCPCS COMBO 1, 2609.45,OTHER, 276.02, 5105.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19029,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2239.96,,OUTPAT REV HCPCS COMBO 1, 2609.45,OTHER, 276.02, 5105.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19030,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19031,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19032,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2571.41,,OUTPAT REV HCPCS COMBO 1, 3021.78,OTHER, 426.91, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19033,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2571.41,,OUTPAT REV HCPCS COMBO 1, 3021.78,OTHER, 426.91, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19034,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19035,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19036,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2881.09,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19037,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2881.09,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19038,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2881.09,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19039,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19040,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19041,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19042,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1381.27,,OUTPAT REV HCPCS COMBO 1, 1689.68,OTHER, 508.57, 3148.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19043,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1381.27,,OUTPAT REV HCPCS COMBO 1, 1689.68,OTHER, 508.57, 3148.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19044,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19045,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19046,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1454.34,,OUTPAT REV HCPCS COMBO 1, 1837.06,OTHER, 779.04, 3314.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19047,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19048,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1075.00,,OUTPAT REV HCPCS COMBO 1, 2098.35,OTHER, 1075.00, 3967.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19049,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1740.64,,OUTPAT REV HCPCS COMBO 1, 2098.35,OTHER, 1075.00, 3967.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19050,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19051,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19052,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19053,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 300.14,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19054,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 300.14,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19055,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 300.14,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19056,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19057,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19058,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 472.37,,OUTPAT REV HCPCS COMBO 1, 704.06,OTHER, 472.37, 1076.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19059,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19060,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 166.15,,OUTPAT REV HCPCS COMBO 1, 248.14,OTHER, 166.15, 378.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19061,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19062,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 326.19,,OUTPAT REV HCPCS COMBO 1, 429.88,OTHER, 249.71, 743.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19063,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19064,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1213.11,,OUTPAT REV HCPCS COMBO 1, 1495.57,OTHER, 495.38, 2764.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19065,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1213.11,,OUTPAT REV HCPCS COMBO 1, 1495.57,OTHER, 495.38, 2764.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19066,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19067,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19068,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 150.50,,OUTPAT REV HCPCS COMBO 1, 224.32,OTHER, 150.50, 343.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19069,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19070,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 309.81,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19071,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 309.81,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19072,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 309.81,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19073,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19074,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19075,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19076,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 233.31,,OUTPAT REV HCPCS COMBO 1, 286.59,OTHER, 90.89, 531.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19077,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19078,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 219.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19079,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 219.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19080,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 219.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19081,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 225.75,,OUTPAT REV HCPCS COMBO 1, 288.12,OTHER, 133.37, 514.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19082,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19083,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19084,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19085,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19086,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 413.68,,OUTPAT REV HCPCS COMBO 1, 503.49,OTHER, 141.55, 942.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19087,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19088,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19089,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19090,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19091,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19092,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19093,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19094,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19095,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19096,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19097,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19098,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 468.07,OTHER, 163.97, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19099,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19100,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19101,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19102,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19103,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19104,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 335.33,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19105,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19106,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19107,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19108,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19109,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19110,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 335.33,,OUTPAT REV HCPCS COMBO 1, 414.50,OTHER, 141.55, 764.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19111,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19112,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 161.25,,OUTPAT REV HCPCS COMBO 1, 214.87,OTHER, 133.37, 367.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19113,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19114,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 330.24,,OUTPAT REV HCPCS COMBO 1, 408.73,OTHER, 141.55, 752.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19115,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19116,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 417.26,,OUTPAT REV HCPCS COMBO 1, 507.55,OTHER, 141.55, 950.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19117,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19118,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 663.92,,OUTPAT REV HCPCS COMBO 1, 775.60,OTHER, 90.89, 1513.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19119,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19120,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 227.90,,OUTPAT REV HCPCS COMBO 1, 290.56,OTHER, 133.37, 519.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19121,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19122,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 339.97,,OUTPAT REV HCPCS COMBO 1, 419.77,OTHER, 141.55, 774.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19123,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19124,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 385.59,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19125,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 385.59,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19126,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 385.59,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19127,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19128,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19129,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19130,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 269.07,,OUTPAT REV HCPCS COMBO 1, 322.12,OTHER, 90.89, 613.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19131,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 260.12,,OUTPAT REV HCPCS COMBO 1, 322.12,OTHER, 90.89, 613.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19132,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19133,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19134,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 330.02,,OUTPAT REV HCPCS COMBO 1, 408.48,OTHER, 141.55, 752.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19135,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19136,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 688.00,,OUTPAT REV HCPCS COMBO 1, 813.95,OTHER, 137.10, 1568.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19137,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 435.01,,OUTPAT REV HCPCS COMBO 1, 526.64,OTHER, 137.10, 991.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19138,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 435.01,,OUTPAT REV HCPCS COMBO 1, 526.64,OTHER, 137.10, 991.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19139,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19140,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19141,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19142,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19143,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 236.50,,OUTPAT REV HCPCS COMBO 1, 300.33,OTHER, 133.37, 539.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19144,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19145,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19146,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19147,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19148,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19149,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19150,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19151,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19152,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19153,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19154,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19155,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19156,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19157,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19158,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19159,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19160,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 285.90,,OUTPAT REV HCPCS COMBO 1, 426.14,OTHER, 285.90, 651.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19161,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19162,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 182.57,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19163,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 182.57,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19164,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 182.57,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19165,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19166,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19167,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19168,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19169,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 186.51,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19170,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 186.51,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19171,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 61.06,,OUTPAT REV HCPCS COMBO 1, 91.01,OTHER, 61.06, 139.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19172,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 21.15,,OUTPAT REV HCPCS COMBO 1, 78.82,OTHER, 21.15, 181.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19173,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19174,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19175,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19176,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19177,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19178,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19179,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19180,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19181,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 210.70,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19182,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 175.87,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19183,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 210.70,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19184,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19185,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19186,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19187,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19188,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19189,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19190,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19191,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19192,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19193,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19194,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19195,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19196,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19197,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19198,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19199,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19200,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 73.53,,OUTPAT REV HCPCS COMBO 1, 116.40,OTHER, 73.53, 167.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19201,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19202,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 315.98,,OUTPAT REV HCPCS COMBO 1, 414.07,OTHER, 232.03, 720.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19203,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 84.28,,OUTPAT REV HCPCS COMBO 1, 158.67,OTHER, 84.28, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19204,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 150.93,,OUTPAT REV HCPCS COMBO 1, 158.67,OTHER, 84.28, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19205,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19206,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19207,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 127.28,,OUTPAT REV HCPCS COMBO 1, 154.63,OTHER, 42.36, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19208,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 150.93,,OUTPAT REV HCPCS COMBO 1, 204.30,OTHER, 138.19, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19209,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19210,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 549.04,,OUTPAT REV HCPCS COMBO 1, 660.83,OTHER, 156.82, 1251.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19211,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 549.04,,OUTPAT REV HCPCS COMBO 1, 660.83,OTHER, 156.82, 1251.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19212,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19213,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19214,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 426.80,,OUTPAT REV HCPCS COMBO 1, 533.81,OTHER, 206.35, 972.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19215,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 426.80,,OUTPAT REV HCPCS COMBO 1, 533.81,OTHER, 206.35, 972.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19216,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19217,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19218,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 600.24,,OUTPAT REV HCPCS COMBO 1, 757.92,OTHER, 320.35, 1367.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19219,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19220,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 724.72,,OUTPAT REV HCPCS COMBO 1, 899.81,OTHER, 322.62, 1651.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19221,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19222,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 847.10,,OUTPAT REV HCPCS COMBO 1, 1092.65,OTHER, 548.80, 1930.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19223,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19224,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 672.15,,OUTPAT REV HCPCS COMBO 1, 864.03,OTHER, 423.08, 1531.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19225,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19226,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 215.00,,OUTPAT REV HCPCS COMBO 1, 344.89,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19227,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19228,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 645.00,,OUTPAT REV HCPCS COMBO 1, 830.31,OTHER, 410.92, 1470.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19229,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19230,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 885.80,,OUTPAT REV HCPCS COMBO 1, 1103.77,OTHER, 410.92, 2018.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19231,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19232,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1111.16,OTHER, 359.95, 2058.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19233,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19234,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 474.08,,OUTPAT REV HCPCS COMBO 1, 624.07,OTHER, 359.95, 1080.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19235,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19236,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 516.57,,OUTPAT REV HCPCS COMBO 1, 672.34,OTHER, 360.01, 1177.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19237,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19238,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 417.10,,OUTPAT REV HCPCS COMBO 1, 559.38,OTHER, 360.01, 950.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19239,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19240,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1005.92,,OUTPAT REV HCPCS COMBO 1, 1228.06,OTHER, 360.01, 2292.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19241,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19242,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1064.04,,OUTPAT REV HCPCS COMBO 1, 1294.05,OTHER, 360.01, 2425.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19243,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19244,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 470.85,,OUTPAT REV HCPCS COMBO 1, 701.80,OTHER, 470.85, 1073.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19245,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19246,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 775.51,,OUTPAT REV HCPCS COMBO 1, 1149.19,OTHER, 775.51, 1767.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19247,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 775.51,,OUTPAT REV HCPCS COMBO 1, 1149.19,OTHER, 775.51, 1767.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19248,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19249,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19250,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1760.54,,OUTPAT REV HCPCS COMBO 1, 2267.81,OTHER, 1127.76, 4012.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19251,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19252,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 624.40,,OUTPAT REV HCPCS COMBO 1, 815.01,OTHER, 444.92, 1423.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19253,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 624.40,,OUTPAT REV HCPCS COMBO 1, 815.01,OTHER, 444.92, 1423.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19254,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19255,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19256,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 500.41,,OUTPAT REV HCPCS COMBO 1, 635.79,OTHER, 283.54, 1140.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19257,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19258,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 803.60,,OUTPAT REV HCPCS COMBO 1, 984.09,OTHER, 300.36, 1831.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19259,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19260,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 831.76,,OUTPAT REV HCPCS COMBO 1, 1050.06,OTHER, 443.12, 1895.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19261,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19262,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 447.20,,OUTPAT REV HCPCS COMBO 1, 684.67,OTHER, 447.20, 1019.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19263,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19264,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2048.52,,OUTPAT REV HCPCS COMBO 1, 2685.69,OTHER, 1509.32, 4668.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19265,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19266,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2121.62,,OUTPAT REV HCPCS COMBO 1, 2768.70,OTHER, 1509.32, 4835.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19267,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19268,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 26.05,,OUTPAT REV HCPCS COMBO 1, 34.30,OTHER, 19.78, 59.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19269,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 26.05,,OUTPAT REV HCPCS COMBO 1, 32.49,OTHER, 12.18, 59.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19270,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 267.46,,OUTPAT REV HCPCS COMBO 1, 398.65,OTHER, 267.46, 609.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19271,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 60.14,,OUTPAT REV HCPCS COMBO 1, 70.69,OTHER, 10.09, 137.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19272,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 104.38,,OUTPAT REV HCPCS COMBO 1, 122.16,OTHER, 15.20, 237.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19273,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 81.90,,OUTPAT REV HCPCS COMBO 1, 97.60,OTHER, 19.28, 186.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19274,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 81.90,,OUTPAT REV HCPCS COMBO 1, 97.60,OTHER, 19.28, 186.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19275,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 70.95,,OUTPAT REV HCPCS COMBO 1, 83.55,OTHER, 12.50, 161.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19276,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 70.95,,OUTPAT REV HCPCS COMBO 1, 83.55,OTHER, 12.50, 161.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19277,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 122.86,,OUTPAT REV HCPCS COMBO 1, 155.85,OTHER, 68.59, 280.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19278,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 67.08,,OUTPAT REV HCPCS COMBO 1, 78.98,OTHER, 11.76, 152.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19279,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 56.33,,OUTPAT REV HCPCS COMBO 1, 69.30,OTHER, 22.37, 128.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19280,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 192.21,,OUTPAT REV HCPCS COMBO 1, 229.30,OTHER, 46.28, 438.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19281,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 75.79,,OUTPAT REV HCPCS COMBO 1, 88.95,OTHER, 20.98, 172.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19282,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 72.07,,OUTPAT REV HCPCS COMBO 1, 88.95,OTHER, 20.98, 172.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19283,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 53.39,OTHER, 19.13, 98.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19284,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 53.39,OTHER, 19.13, 98.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19285,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 66.51,,OUTPAT REV HCPCS COMBO 1, 80.17,OTHER, 19.50, 151.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19286,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 41.55,,OUTPAT REV HCPCS COMBO 1, 54.61,OTHER, 31.20, 94.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19287,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 66.47,,OUTPAT REV HCPCS COMBO 1, 80.03,OTHER, 19.08, 151.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19288,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.72,,OUTPAT REV HCPCS COMBO 1, 79.17,OTHER, 19.08, 149.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19289,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 54.32,,OUTPAT REV HCPCS COMBO 1, 63.95,OTHER, 9.52, 123.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19290,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 20.21,,OUTPAT REV HCPCS COMBO 1, 28.28,OTHER, 20.21, 46.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19291,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 69.69,,OUTPAT REV HCPCS COMBO 1, 83.69,OTHER, 19.08, 158.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19292,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 42.46,,OUTPAT REV HCPCS COMBO 1, 53.47,OTHER, 22.03, 96.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19293,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 66.28,,OUTPAT REV HCPCS COMBO 1, 79.81,OTHER, 19.08, 151.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19294,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 35.17,,OUTPAT REV HCPCS COMBO 1, 44.64,OTHER, 19.78, 80.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19295,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 124.34,,OUTPAT REV HCPCS COMBO 1, 145.91,OTHER, 19.78, 283.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19296,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 52.76,,OUTPAT REV HCPCS COMBO 1, 64.76,OTHER, 20.36, 120.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19297,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 103.25,,OUTPAT REV HCPCS COMBO 1, 121.34,OTHER, 17.16, 235.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19298,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 70.55,,OUTPAT REV HCPCS COMBO 1, 84.76,OTHER, 19.50, 160.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19299,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 111.79,,OUTPAT REV HCPCS COMBO 1, 134.69,OTHER, 32.53, 254.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19300,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 74.42,,OUTPAT REV HCPCS COMBO 1, 90.91,OTHER, 26.84, 169.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19301,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 81.85,,OUTPAT REV HCPCS COMBO 1, 56.90,OTHER, 10.75, 186.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19302,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 56.90,OTHER, 10.75, 186.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19303,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 17.20,,OUTPAT REV HCPCS COMBO 1, 23.85,OTHER, 17.20, 39.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19304,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 17.20,,OUTPAT REV HCPCS COMBO 1, 23.85,OTHER, 17.20, 39.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19305,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 112.61,,OUTPAT REV HCPCS COMBO 1, 178.46,OTHER, 112.61, 289.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19306,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 126.85,,OUTPAT REV HCPCS COMBO 1, 178.46,OTHER, 112.61, 289.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19307,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 72.67,,OUTPAT REV HCPCS COMBO 1, 108.31,OTHER, 72.67, 165.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19308,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 64.50,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19309,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.68,,OUTPAT REV HCPCS COMBO 1, 48.71,OTHER, 32.68, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19310,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 120.73,,OUTPAT REV HCPCS COMBO 1, 179.95,OTHER, 120.73, 275.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19311,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 76.91,,OUTPAT REV HCPCS COMBO 1, 114.63,OTHER, 76.91, 175.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19312,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 17.56,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19313,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19314,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 17.56,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19315,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 17.56,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19316,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 60.63,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19317,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.53,,OUTPAT REV HCPCS COMBO 1, 67.87,OTHER, 45.53, 103.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19318,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 68.37,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19319,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 68.37,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19320,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 68.37,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19321,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 58.05,,OUTPAT REV HCPCS COMBO 1, 86.52,OTHER, 58.05, 132.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19322,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 120.81,OTHER, 36.98, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19323,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 120.81,OTHER, 36.98, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19324,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 29.76,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19325,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 29.76,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19326,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 29.76,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19327,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 17.75,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19328,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 17.75,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19329,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 17.75,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19330,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 5.59,,OUTPAT REV HCPCS COMBO 1, 7.12,OTHER, 3.24, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19331,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 8.07,OTHER, 3.12, 14.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19332,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 27.22,,OUTPAT REV HCPCS COMBO 1, 33.86,OTHER, 12.40, 62.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19333,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 27.22,,OUTPAT REV HCPCS COMBO 1, 33.86,OTHER, 12.40, 62.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19334,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 64.07,,OUTPAT REV HCPCS COMBO 1, 75.71,OTHER, 12.40, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19335,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 64.07,,OUTPAT REV HCPCS COMBO 1, 75.71,OTHER, 12.40, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19336,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 106.06,,OUTPAT REV HCPCS COMBO 1, 145.60,OTHER, 105.66, 241.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19337,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 106.06,,OUTPAT REV HCPCS COMBO 1, 145.60,OTHER, 105.66, 241.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19338,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 211.56,,OUTPAT REV HCPCS COMBO 1, 262.66,OTHER, 94.12, 482.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19339,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 350.08,,OUTPAT REV HCPCS COMBO 1, 428.98,OTHER, 131.99, 797.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19340,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 87.01,,OUTPAT REV HCPCS COMBO 1, 129.68,OTHER, 87.01, 198.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19341,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 164.26,,OUTPAT REV HCPCS COMBO 1, 244.83,OTHER, 164.26, 374.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19342,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 164.26,,OUTPAT REV HCPCS COMBO 1, 244.83,OTHER, 164.26, 374.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19343,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.44,,OUTPAT REV HCPCS COMBO 1, 53.15,OTHER, 6.50, 103.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19344,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 31.79,,OUTPAT REV HCPCS COMBO 1, 38.90,OTHER, 11.76, 72.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19345,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 117.64,,OUTPAT REV HCPCS COMBO 1, 146.83,OTHER, 55.61, 268.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19346,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 16.23,,OUTPAT REV HCPCS COMBO 1, 20.13,OTHER, 7.13, 37.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19347,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 16.23,,OUTPAT REV HCPCS COMBO 1, 20.13,OTHER, 7.13, 37.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19348,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 23.11,,OUTPAT REV HCPCS COMBO 1, 28.92,OTHER, 11.21, 52.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19349,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 23.11,,OUTPAT REV HCPCS COMBO 1, 28.92,OTHER, 11.21, 52.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19350,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 51.60,,OUTPAT REV HCPCS COMBO 1, 60.58,OTHER, 8.33, 117.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19351,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 51.60,,OUTPAT REV HCPCS COMBO 1, 60.58,OTHER, 8.33, 117.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19352,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 41.87,,OUTPAT REV HCPCS COMBO 1, 50.88,OTHER, 13.98, 95.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19353,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 58.52,,OUTPAT REV HCPCS COMBO 1, 71.06,OTHER, 19.36, 133.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19354,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 92.38,,OUTPAT REV HCPCS COMBO 1, 109.86,OTHER, 20.82, 210.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19355,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.53,,OUTPAT REV HCPCS COMBO 1, 80.16,OTHER, 24.14, 149.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19356,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.53,,OUTPAT REV HCPCS COMBO 1, 80.16,OTHER, 24.14, 149.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19357,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 63.10,OTHER, 20.98, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19358,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 63.10,OTHER, 20.98, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19359,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 42.77,,OUTPAT REV HCPCS COMBO 1, 50.79,OTHER, 9.34, 97.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19360,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 42.77,,OUTPAT REV HCPCS COMBO 1, 50.79,OTHER, 9.34, 97.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19361,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 79.55,,OUTPAT REV HCPCS COMBO 1, 100.38,OTHER, 42.16, 181.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19362,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 97.65,,OUTPAT REV HCPCS COMBO 1, 121.92,OTHER, 46.34, 222.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19363,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 37.84,,OUTPAT REV HCPCS COMBO 1, 50.20,OTHER, 30.37, 86.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19364,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 96.70,,OUTPAT REV HCPCS COMBO 1, 116.31,OTHER, 27.31, 220.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19365,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 40.85,,OUTPAT REV HCPCS COMBO 1, 49.78,OTHER, 14.24, 93.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19366,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 50.98,,OUTPAT REV HCPCS COMBO 1, 63.44,OTHER, 23.30, 116.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19367,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 30.50,,OUTPAT REV HCPCS COMBO 1, 36.36,OTHER, 7.22, 69.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19368,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 30.50,,OUTPAT REV HCPCS COMBO 1, 36.36,OTHER, 7.22, 69.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19369,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 27.61,,OUTPAT REV HCPCS COMBO 1, 33.07,OTHER, 7.22, 62.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19370,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 15.70,,OUTPAT REV HCPCS COMBO 1, 19.33,OTHER, 6.31, 35.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19371,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.02,,OUTPAT REV HCPCS COMBO 1, 33.34,OTHER, 6.38, 63.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19372,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 56.73,OTHER, 22.92, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19373,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 100.38,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19374,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 107.07,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19375,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 100.38,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19376,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 100.80,,OUTPAT REV HCPCS COMBO 1, 123.66,OTHER, 38.58, 229.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19377,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.45,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19378,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.45,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19379,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.45,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19380,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 56.84,,OUTPAT REV HCPCS COMBO 1, 69.24,OTHER, 19.70, 129.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19381,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 42.18,,OUTPAT REV HCPCS COMBO 1, 49.97,OTHER, 8.69, 96.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19382,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 35.26,,OUTPAT REV HCPCS COMBO 1, 44.47,OTHER, 18.58, 80.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19383,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 53.64,,OUTPAT REV HCPCS COMBO 1, 65.14,OTHER, 17.74, 122.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19384,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 71.10,,OUTPAT REV HCPCS COMBO 1, 87.25,OTHER, 27.30, 162.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19385,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 71.10,,OUTPAT REV HCPCS COMBO 1, 87.25,OTHER, 27.30, 162.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19386,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 46.87,,OUTPAT REV HCPCS COMBO 1, 59.01,OTHER, 24.29, 106.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19387,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 104.53,,OUTPAT REV HCPCS COMBO 1, 127.93,OTHER, 36.36, 240.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19388,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 105.53,,OUTPAT REV HCPCS COMBO 1, 127.93,OTHER, 36.36, 240.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19389,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.46,OTHER, 15.47, 105.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19390,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 10.32,,OUTPAT REV HCPCS COMBO 1, 13.69,OTHER, 8.28, 23.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19391,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 61.16,,OUTPAT REV HCPCS COMBO 1, 73.71,OTHER, 17.87, 139.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19392,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 72.21,,OUTPAT REV HCPCS COMBO 1, 87.73,OTHER, 24.06, 164.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19393,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 72.21,,OUTPAT REV HCPCS COMBO 1, 87.73,OTHER, 24.06, 164.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19394,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 53.47,,OUTPAT REV HCPCS COMBO 1, 66.31,OTHER, 23.47, 121.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19395,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 53.47,,OUTPAT REV HCPCS COMBO 1, 66.31,OTHER, 23.47, 121.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19396,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 160.20,,OUTPAT REV HCPCS COMBO 1, 190.19,OTHER, 34.69, 365.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19397,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 181.18,,OUTPAT REV HCPCS COMBO 1, 214.01,OTHER, 34.69, 412.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19398,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 39.85,,OUTPAT REV HCPCS COMBO 1, 47.49,OTHER, 9.37, 90.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19399,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 39.85,,OUTPAT REV HCPCS COMBO 1, 47.49,OTHER, 9.37, 90.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19400,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.68,,OUTPAT REV HCPCS COMBO 1, 41.70,OTHER, 19.28, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19401,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 49.11,,OUTPAT REV HCPCS COMBO 1, 59.73,OTHER, 16.63, 111.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19402,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 26.30,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19403,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 26.30,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19404,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 26.30,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19405,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.88,,OUTPAT REV HCPCS COMBO 1, 39.11,OTHER, 7.46, 74.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19406,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.88,,OUTPAT REV HCPCS COMBO 1, 39.11,OTHER, 7.46, 74.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19407,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 79.45,,OUTPAT REV HCPCS COMBO 1, 93.47,OTHER, 13.62, 181.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19408,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 79.45,,OUTPAT REV HCPCS COMBO 1, 93.47,OTHER, 13.62, 181.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19409,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.12,,OUTPAT REV HCPCS COMBO 1, 45.06,OTHER, 16.97, 82.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19410,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.16,,OUTPAT REV HCPCS COMBO 1, 76.21,OTHER, 9.31, 148.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19411,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 59.05,,OUTPAT REV HCPCS COMBO 1, 72.23,OTHER, 21.72, 134.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19412,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 59.05,,OUTPAT REV HCPCS COMBO 1, 72.23,OTHER, 21.72, 134.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19413,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 60.77,,OUTPAT REV HCPCS COMBO 1, 75.36,OTHER, 26.66, 138.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19414,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 60.77,,OUTPAT REV HCPCS COMBO 1, 75.36,OTHER, 26.66, 138.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19415,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 104.58,,OUTPAT REV HCPCS COMBO 1, 127.42,OTHER, 36.38, 238.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19416,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 104.58,,OUTPAT REV HCPCS COMBO 1, 127.42,OTHER, 36.38, 238.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19417,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 76.99,,OUTPAT REV HCPCS COMBO 1, 93.87,OTHER, 27.06, 175.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19418,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 110.87,,OUTPAT REV HCPCS COMBO 1, 135.49,OTHER, 40.24, 252.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19419,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 110.87,,OUTPAT REV HCPCS COMBO 1, 135.49,OTHER, 40.24, 252.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19420,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 64.07,,OUTPAT REV HCPCS COMBO 1, 83.83,OTHER, 46.51, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19421,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 57.62,,OUTPAT REV HCPCS COMBO 1, 73.72,OTHER, 34.82, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19422,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 58.91,,OUTPAT REV HCPCS COMBO 1, 75.45,OTHER, 35.93, 134.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19423,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 100.08,,OUTPAT REV HCPCS COMBO 1, 121.64,OTHER, 33.53, 228.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19424,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 59.37,,OUTPAT REV HCPCS COMBO 1, 69.17,OTHER, 7.34, 135.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19425,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 104.71,,OUTPAT REV HCPCS COMBO 1, 124.67,OTHER, 24.19, 238.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19426,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 63.21,,OUTPAT REV HCPCS COMBO 1, 76.46,OTHER, 19.63, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19427,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 58.51,,OUTPAT REV HCPCS COMBO 1, 71.48,OTHER, 21.17, 133.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19428,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 182.22,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19429,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 66.65,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19430,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.48,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19431,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.48,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19432,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.48,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19433,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 52.23,,OUTPAT REV HCPCS COMBO 1, 64.96,OTHER, 23.70, 119.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19434,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.38,,OUTPAT REV HCPCS COMBO 1, 34.98,OTHER, 11.54, 64.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19435,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 171.35,,OUTPAT REV HCPCS COMBO 1, 203.52,OTHER, 37.54, 390.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19436,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 49.02,,OUTPAT REV HCPCS COMBO 1, 61.71,OTHER, 25.39, 111.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19437,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 21.39,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19438,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 21.39,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19439,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 21.39,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19440,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 23.75,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19441,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 23.75,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19442,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 23.75,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19443,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 11.27,,OUTPAT REV HCPCS COMBO 1, 14.14,OTHER, 5.66, 25.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19444,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 55.33,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 6.84, 126.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19445,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 55.33,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 6.84, 126.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19446,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 48.07,,OUTPAT REV HCPCS COMBO 1, 57.91,OTHER, 13.97, 109.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19447,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 30.89,,OUTPAT REV HCPCS COMBO 1, 37.55,OTHER, 10.37, 70.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19448,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 77.81,,OUTPAT REV HCPCS COMBO 1, 94.73,OTHER, 26.76, 177.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19449,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 77.81,,OUTPAT REV HCPCS COMBO 1, 94.73,OTHER, 26.76, 177.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19450,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 77.64,,OUTPAT REV HCPCS COMBO 1, 94.52,OTHER, 26.66, 176.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19451,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 77.64,,OUTPAT REV HCPCS COMBO 1, 94.52,OTHER, 26.66, 176.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19452,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 55.24,,OUTPAT REV HCPCS COMBO 1, 67.05,OTHER, 18.12, 125.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19453,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 59.34,,OUTPAT REV HCPCS COMBO 1, 74.92,OTHER, 31.62, 135.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19454,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 39.60,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19455,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 39.60,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19456,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 39.60,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19457,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 82.50,,OUTPAT REV HCPCS COMBO 1, 99.83,OTHER, 25.80, 188.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19458,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 129.43,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19459,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19460,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19461,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19462,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19463,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19464,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 127.54,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19465,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 77.00,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19466,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 118.72,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19467,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 18.49,,OUTPAT REV HCPCS COMBO 1, 25.93,OTHER, 18.49, 42.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19468,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 57.34,,OUTPAT REV HCPCS COMBO 1, 69.04,OTHER, 16.46, 130.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19469,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.69,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19470,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.69,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19471,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.69,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19472,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19473,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19474,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19475,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19476,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 58.18,,OUTPAT REV HCPCS COMBO 1, 70.04,OTHER, 16.66, 132.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19477,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 37.18,,OUTPAT REV HCPCS COMBO 1, 51.00,OTHER, 8.70, 111.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19478,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 48.99,,OUTPAT REV HCPCS COMBO 1, 51.00,OTHER, 8.70, 111.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19479,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 71.38,,OUTPAT REV HCPCS COMBO 1, 85.45,OTHER, 18.42, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19480,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.77,OTHER, 28.37, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19481,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 44.57,,OUTPAT REV HCPCS COMBO 1, 54.77,OTHER, 17.44, 101.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19482,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 44.57,,OUTPAT REV HCPCS COMBO 1, 54.77,OTHER, 17.44, 101.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19483,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 60.48,OTHER, 9.92, 116.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19484,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 60.48,OTHER, 9.92, 116.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19485,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 117.27,,OUTPAT REV HCPCS COMBO 1, 149.05,OTHER, 66.68, 267.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19486,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 27.95,,OUTPAT REV HCPCS COMBO 1, 43.46,OTHER, 27.95, 63.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19487,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 34.70,,OUTPAT REV HCPCS COMBO 1, 43.01,OTHER, 15.12, 79.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19488,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 34.70,,OUTPAT REV HCPCS COMBO 1, 43.01,OTHER, 15.12, 79.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19489,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 33.76,,OUTPAT REV HCPCS COMBO 1, 40.64,OTHER, 9.65, 76.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19490,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 172.39,,OUTPAT REV HCPCS COMBO 1, 204.04,OTHER, 34.72, 392.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19491,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.72,,OUTPAT REV HCPCS COMBO 1, 57.49,OTHER, 23.41, 104.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19492,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 135.39,,OUTPAT REV HCPCS COMBO 1, 159.56,OTHER, 24.40, 308.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19493,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 135.39,,OUTPAT REV HCPCS COMBO 1, 159.56,OTHER, 24.40, 308.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19494,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 71.67,,OUTPAT REV HCPCS COMBO 1, 74.79,OTHER, 18.60, 163.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19495,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 52.25,,OUTPAT REV HCPCS COMBO 1, 74.79,OTHER, 18.60, 163.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19496,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 94.17,,OUTPAT REV HCPCS COMBO 1, 120.40,OTHER, 56.53, 214.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19497,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 94.17,,OUTPAT REV HCPCS COMBO 1, 120.40,OTHER, 56.53, 214.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19498,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 91.30,,OUTPAT REV HCPCS COMBO 1, 110.95,OTHER, 30.54, 208.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19499,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.70,,OUTPAT REV HCPCS COMBO 1, 54.17,OTHER, 9.52, 104.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19500,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 37.08,,OUTPAT REV HCPCS COMBO 1, 44.45,OTHER, 9.82, 84.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19501,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 37.08,,OUTPAT REV HCPCS COMBO 1, 44.45,OTHER, 9.82, 84.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19502,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 71.50,,OUTPAT REV HCPCS COMBO 1, 86.15,OTHER, 20.81, 162.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19503,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 116.98,,OUTPAT REV HCPCS COMBO 1, 147.00,OTHER, 59.45, 266.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19504,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 116.98,,OUTPAT REV HCPCS COMBO 1, 147.00,OTHER, 59.45, 266.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19505,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.68,,OUTPAT REV HCPCS COMBO 1, 43.75,OTHER, 27.89, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19506,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 158.40,,OUTPAT REV HCPCS COMBO 1, 186.61,OTHER, 28.27, 361.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19507,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 45.87,OTHER, 7.46, 92.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19508,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 40.68,,OUTPAT REV HCPCS COMBO 1, 45.87,OTHER, 7.46, 92.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19509,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 29.56,,OUTPAT REV HCPCS COMBO 1, 35.19,OTHER, 6.83, 67.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19510,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 29.56,,OUTPAT REV HCPCS COMBO 1, 35.19,OTHER, 6.83, 67.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19511,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 23.99,,OUTPAT REV HCPCS COMBO 1, 28.87,OTHER, 6.85, 54.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19512,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 13.83,OTHER, 6.82, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19513,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 35.72,,OUTPAT REV HCPCS COMBO 1, 45.56,OTHER, 21.01, 81.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19514,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 75.35,,OUTPAT REV HCPCS COMBO 1, 92.72,OTHER, 30.04, 171.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19515,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 75.35,,OUTPAT REV HCPCS COMBO 1, 92.72,OTHER, 30.04, 171.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19516,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 82.30,,OUTPAT REV HCPCS COMBO 1, 102.79,OTHER, 39.19, 187.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19517,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 79.71,,OUTPAT REV HCPCS COMBO 1, 97.17,OTHER, 27.91, 181.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19518,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 71.08,,OUTPAT REV HCPCS COMBO 1, 90.21,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19519,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 76.69,,OUTPAT REV HCPCS COMBO 1, 90.21,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19520,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 76.69,,OUTPAT REV HCPCS COMBO 1, 93.39,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19521,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 20.61,,OUTPAT REV HCPCS COMBO 1, 24.66,OTHER, 5.28, 46.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19522,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 20.61,,OUTPAT REV HCPCS COMBO 1, 24.66,OTHER, 5.28, 46.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19523,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19524,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19525,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19526,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 35.17,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19527,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 35.17,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19528,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.73,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19529,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 171.18,,OUTPAT REV HCPCS COMBO 1, 144.06,OTHER, 15.47, 390.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19530,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 76.05,,OUTPAT REV HCPCS COMBO 1, 144.06,OTHER, 15.47, 390.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19531,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.58,,OUTPAT REV HCPCS COMBO 1, 141.59,OTHER, 25.68, 394.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19532,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 173.02,,OUTPAT REV HCPCS COMBO 1, 141.59,OTHER, 25.68, 394.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19533,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 112.01,,OUTPAT REV HCPCS COMBO 1, 136.35,OTHER, 38.44, 255.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19534,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 82.46,,OUTPAT REV HCPCS COMBO 1, 103.27,OTHER, 40.46, 187.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19535,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 61.06,,OUTPAT REV HCPCS COMBO 1, 76.88,OTHER, 31.67, 139.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19536,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 151.36,,OUTPAT REV HCPCS COMBO 1, 178.83,OTHER, 29.15, 344.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19537,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 71.31,,OUTPAT REV HCPCS COMBO 1, 88.43,OTHER, 31.30, 162.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19538,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 24.98,,OUTPAT REV HCPCS COMBO 1, 30.02,OTHER, 6.92, 56.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19539,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 24.98,,OUTPAT REV HCPCS COMBO 1, 30.02,OTHER, 6.92, 56.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19540,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 38.86,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19541,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 38.86,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19542,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 7.98,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19543,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 152.72,,OUTPAT REV HCPCS COMBO 1, 180.72,OTHER, 30.61, 348.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19544,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 264.33,,OUTPAT REV HCPCS COMBO 1, 302.95,OTHER, 11.66, 602.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19545,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 64.43,,OUTPAT REV HCPCS COMBO 1, 81.90,OTHER, 36.67, 146.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19546,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19547,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19548,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19549,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19550,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 70.02,,OUTPAT REV HCPCS COMBO 1, 86.80,OTHER, 30.58, 159.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19551,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 70.02,,OUTPAT REV HCPCS COMBO 1, 86.80,OTHER, 30.58, 159.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19552,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 89.69,,OUTPAT REV HCPCS COMBO 1, 107.35,OTHER, 23.12, 204.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19553,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 89.69,,OUTPAT REV HCPCS COMBO 1, 107.35,OTHER, 23.12, 204.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19554,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 44.84,,OUTPAT REV HCPCS COMBO 1, 53.27,OTHER, 9.89, 102.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19555,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 44.84,,OUTPAT REV HCPCS COMBO 1, 53.27,OTHER, 9.89, 102.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19556,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 64.16,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19557,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 64.16,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19558,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 64.16,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19559,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 41.28,,OUTPAT REV HCPCS COMBO 1, 51.95,OTHER, 21.29, 94.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19560,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 59.68,,OUTPAT REV HCPCS COMBO 1, 73.53,OTHER, 24.19, 136.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19561,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 120.40,,OUTPAT REV HCPCS COMBO 1, 154.17,OTHER, 73.24, 274.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19562,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 120.40,,OUTPAT REV HCPCS COMBO 1, 154.17,OTHER, 73.24, 274.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19563,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 39.56,,OUTPAT REV HCPCS COMBO 1, 49.79,OTHER, 20.42, 90.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19564,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.18,,OUTPAT REV HCPCS COMBO 1, 38.32,OTHER, 7.46, 73.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19565,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 30.09,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, 7.63, 68.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19566,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 47.67,,OUTPAT REV HCPCS COMBO 1, 58.51,OTHER, 18.37, 108.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19567,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.73,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 8.27, 74.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19568,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.64,,OUTPAT REV HCPCS COMBO 1, 79.41,OTHER, 20.42, 149.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19569,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.64,,OUTPAT REV HCPCS COMBO 1, 79.41,OTHER, 20.42, 149.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19570,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 64.36,,OUTPAT REV HCPCS COMBO 1, 78.90,OTHER, 24.40, 146.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19571,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 64.36,,OUTPAT REV HCPCS COMBO 1, 78.90,OTHER, 24.40, 146.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19572,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 106.98,,OUTPAT REV HCPCS COMBO 1, 126.89,OTHER, 22.69, 243.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19573,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 69.32,,OUTPAT REV HCPCS COMBO 1, 82.99,OTHER, 17.95, 157.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19574,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 69.32,,OUTPAT REV HCPCS COMBO 1, 82.99,OTHER, 17.95, 157.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19575,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 33.26,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19576,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 33.26,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19577,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 33.26,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19578,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 18.22,,OUTPAT REV HCPCS COMBO 1, 22.60,OTHER, 8.00, 41.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19579,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 18.22,,OUTPAT REV HCPCS COMBO 1, 22.60,OTHER, 8.00, 41.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19580,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 26.70,,OUTPAT REV HCPCS COMBO 1, 31.87,OTHER, 6.50, 60.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19581,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.90,,OUTPAT REV HCPCS COMBO 1, 39.10,OTHER, 7.32, 74.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19582,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 63.71,,OUTPAT REV HCPCS COMBO 1, 76.33,OTHER, 16.72, 145.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19583,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 87.18,,OUTPAT REV HCPCS COMBO 1, 103.71,OTHER, 19.75, 198.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19584,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19585,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19586,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19587,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 69.10,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 29.96, 157.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19588,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 80.90,,OUTPAT REV HCPCS COMBO 1, 97.04,OTHER, 21.67, 184.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19589,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.30,,OUTPAT REV HCPCS COMBO 1, 42.88,OTHER, 6.94, 82.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19590,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 37.42,,OUTPAT REV HCPCS COMBO 1, 43.80,OTHER, 5.47, 85.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19591,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 15.00,,OUTPAT REV HCPCS COMBO 1, 17.85,OTHER, 3.41, 34.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19592,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 15.00,,OUTPAT REV HCPCS COMBO 1, 17.85,OTHER, 3.41, 34.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19593,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 18.18,,OUTPAT REV HCPCS COMBO 1, 21.46,OTHER, 3.41, 41.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19594,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 18.18,,OUTPAT REV HCPCS COMBO 1, 21.46,OTHER, 3.41, 41.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19595,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 22.31,OTHER, .01, 84.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19596,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.94,,OUTPAT REV HCPCS COMBO 1, 22.31,OTHER, .01, 84.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19597,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 37.42,,OUTPAT REV HCPCS COMBO 1, 44.71,OTHER, 9.31, 85.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19598,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 31.95,,OUTPAT REV HCPCS COMBO 1, 37.65,OTHER, 5.75, 72.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19599,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 31.95,,OUTPAT REV HCPCS COMBO 1, 37.65,OTHER, 5.75, 72.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19600,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 16.77,,OUTPAT REV HCPCS COMBO 1, 19.92,OTHER, 3.66, 38.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19601,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 27.38,,OUTPAT REV HCPCS COMBO 1, 32.63,OTHER, 6.46, 62.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19602,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 79.81,,OUTPAT REV HCPCS COMBO 1, 96.77,OTHER, 25.78, 181.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19603,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 106.94,,OUTPAT REV HCPCS COMBO 1, 129.31,OTHER, 33.04, 243.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19604,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 111.37,,OUTPAT REV HCPCS COMBO 1, 130.54,OTHER, 17.06, 253.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19605,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 82.42,,OUTPAT REV HCPCS COMBO 1, 98.34,OTHER, 19.93, 187.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19606,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 73.75,,OUTPAT REV HCPCS COMBO 1, 89.00,OTHER, 22.06, 168.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19607,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 83.42,,OUTPAT REV HCPCS COMBO 1, 98.22,OTHER, 14.66, 190.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19608,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.18,,OUTPAT REV HCPCS COMBO 1, 54.63,OTHER, 13.99, 102.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19609,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 56.33,,OUTPAT REV HCPCS COMBO 1, 70.40,OTHER, 27.00, 128.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19610,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 25.05,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19611,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 24.89,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19612,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 25.05,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19613,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19614,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19615,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19616,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19617,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 35.35,,OUTPAT REV HCPCS COMBO 1, 41.60,OTHER, 6.14, 80.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19618,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 22.36,,OUTPAT REV HCPCS COMBO 1, 26.32,OTHER, 3.89, 50.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19619,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 30.35,,OUTPAT REV HCPCS COMBO 1, 36.35,OTHER, 7.93, 69.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19620,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 73.10,,OUTPAT REV HCPCS COMBO 1, 61.85,OTHER, 8.65, 166.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19621,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.20,,OUTPAT REV HCPCS COMBO 1, 61.85,OTHER, 8.65, 166.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19622,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.15,,OUTPAT REV HCPCS COMBO 1, 76.67,OTHER, 11.26, 148.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19623,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 510.99,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19624,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 138.89,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19625,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19626,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19627,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19628,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19629,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19630,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19631,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19632,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19633,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19634,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19635,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19636,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19637,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19638,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19639,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19640,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19641,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19642,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19643,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19644,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19645,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19646,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19647,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19648,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19649,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19650,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19651,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19652,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19653,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19654,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19655,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19656,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19657,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19658,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19659,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19660,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19661,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 26.51,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19662,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19663,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19664,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19665,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19666,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 13.80,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19667,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19668,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19669,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19670,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19671,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19672,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19673,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19674,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19675,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19676,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19677,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19678,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19679,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19680,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19681,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19682,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19683,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19684,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19685,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 161.14,,OUTPAT REV HCPCS COMBO 1, 189.29,OTHER, 26.45, 367.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19686,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 98.39,,OUTPAT REV HCPCS COMBO 1, 115.17,OTHER, 14.46, 224.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19687,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 57.32,,OUTPAT REV HCPCS COMBO 1, 91.70,OTHER, 17.41, 220.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19688,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 96.87,,OUTPAT REV HCPCS COMBO 1, 91.70,OTHER, 17.41, 220.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19689,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 39.70,,OUTPAT REV HCPCS COMBO 1, 48.91,OTHER, 16.07, 90.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19690,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 37.63,,OUTPAT REV HCPCS COMBO 1, 45.23,OTHER, 10.51, 85.75,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19691,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 13.48,,OUTPAT REV HCPCS COMBO 1, 17.08,OTHER, 7.46, 30.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19692,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 13.48,,OUTPAT REV HCPCS COMBO 1, 17.08,OTHER, 7.46, 30.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19693,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 48.27,,OUTPAT REV HCPCS COMBO 1, 59.25,OTHER, 18.65, 110.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19694,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 75.07,,OUTPAT REV HCPCS COMBO 1, 93.98,OTHER, 36.65, 171.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19695,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 113.28,,OUTPAT REV HCPCS COMBO 1, 137.37,OTHER, 36.65, 258.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19696,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 64.24,,OUTPAT REV HCPCS COMBO 1, 78.46,OTHER, 23.14, 146.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19697,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 56.01,,OUTPAT REV HCPCS COMBO 1, 67.64,OTHER, 17.28, 127.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19698,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 55.87,,OUTPAT REV HCPCS COMBO 1, 67.64,OTHER, 17.28, 127.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19699,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 62.28,,OUTPAT REV HCPCS COMBO 1, 77.69,OTHER, 29.26, 141.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19700,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 51.73,,OUTPAT REV HCPCS COMBO 1, 63.19,OTHER, 18.65, 117.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19701,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 51.66,,OUTPAT REV HCPCS COMBO 1, 65.88,OTHER, 19.79, 127.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19702,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 56.08,,OUTPAT REV HCPCS COMBO 1, 65.88,OTHER, 19.79, 127.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19703,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19704,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19705,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19706,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19707,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 60.90,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19708,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19709,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 51.97,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19710,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 48.44,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19711,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 68.37,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19712,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 104.56,,OUTPAT REV HCPCS COMBO 1, 120.82,OTHER, 17.35, 238.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19713,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 100.94,,OUTPAT REV HCPCS COMBO 1, 120.82,OTHER, 17.35, 238.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19714,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 15.65,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19715,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 64.09,,OUTPAT REV HCPCS COMBO 1, 80.94,OTHER, 29.96, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19716,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.89,,OUTPAT REV HCPCS COMBO 1, 80.94,OTHER, 29.96, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19717,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 68.68,,OUTPAT REV HCPCS COMBO 1, 85.12,OTHER, 29.96, 156.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19718,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 84.81,,OUTPAT REV HCPCS COMBO 1, 103.45,OTHER, 29.96, 193.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19719,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 58.18,,OUTPAT REV HCPCS COMBO 1, 125.05,OTHER, 24.97, 345.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19720,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 151.58,,OUTPAT REV HCPCS COMBO 1, 125.05,OTHER, 24.97, 345.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19721,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 42.94,,OUTPAT REV HCPCS COMBO 1, 50.54,OTHER, 7.46, 97.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19722,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 71.51,,OUTPAT REV HCPCS COMBO 1, 88.87,OTHER, 32.17, 162.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19723,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 52.03,,OUTPAT REV HCPCS COMBO 1, 66.43,OTHER, 30.83, 118.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19724,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 46.01,,OUTPAT REV HCPCS COMBO 1, 57.43,OTHER, 21.72, 104.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19725,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 226.29,,OUTPAT REV HCPCS COMBO 1, 265.06,OTHER, 33.95, 515.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19726,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 63.21,,OUTPAT REV HCPCS COMBO 1, 80.97,OTHER, 38.57, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19727,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 63.21,,OUTPAT REV HCPCS COMBO 1, 80.97,OTHER, 38.57, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19728,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 87.08,,OUTPAT REV HCPCS COMBO 1, 111.82,OTHER, 54.34, 198.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19729,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 141.00,,OUTPAT REV HCPCS COMBO 1, 176.22,OTHER, 67.64, 321.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19730,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 69.45,,OUTPAT REV HCPCS COMBO 1, 88.05,OTHER, 38.57, 158.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19731,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 69.45,,OUTPAT REV HCPCS COMBO 1, 88.05,OTHER, 38.57, 158.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19732,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 57.62,,OUTPAT REV HCPCS COMBO 1, 68.73,OTHER, 13.84, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19733,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 70.14,,OUTPAT REV HCPCS COMBO 1, 96.09,OTHER, 20.95, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19734,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 90.30,,OUTPAT REV HCPCS COMBO 1, 96.09,OTHER, 20.95, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19735,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 57.62,,OUTPAT REV HCPCS COMBO 1, 70.10,OTHER, 19.60, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19736,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 39.55,,OUTPAT REV HCPCS COMBO 1, 46.86,OTHER, 8.16, 90.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19737,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 39.55,,OUTPAT REV HCPCS COMBO 1, 46.86,OTHER, 8.16, 90.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19738,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 150.07,,OUTPAT REV HCPCS COMBO 1, 191.67,OTHER, 89.24, 342.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19739,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 8.04,,OUTPAT REV HCPCS COMBO 1, 12.31,OTHER, 8.04, 18.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19740,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 15.01,,OUTPAT REV HCPCS COMBO 1, 18.56,OTHER, 6.34, 34.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19741,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 27.34,,OUTPAT REV HCPCS COMBO 1, 36.21,OTHER, 21.67, 62.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19742,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.58,,OUTPAT REV HCPCS COMBO 1, 55.25,OTHER, 14.66, 103.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19743,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 31.44,,OUTPAT REV HCPCS COMBO 1, 40.13,OTHER, 18.58, 71.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19744,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 66.54,OTHER, 19.00, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19745,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 72.68,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19746,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 72.68,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19747,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 72.68,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19748,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 19.93,,OUTPAT REV HCPCS COMBO 1, 26.75,OTHER, 17.29, 45.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19749,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 41.68,,OUTPAT REV HCPCS COMBO 1, 91.08,OTHER, 16.51, 254.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19750,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 111.80,,OUTPAT REV HCPCS COMBO 1, 91.08,OTHER, 16.51, 254.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19751,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 40.42,,OUTPAT REV HCPCS COMBO 1, 50.83,OTHER, 20.72, 92.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19752,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 46.87,,OUTPAT REV HCPCS COMBO 1, 59.00,OTHER, 24.26, 106.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19753,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 52.14,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 22.02, 118.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19754,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 46.92,,OUTPAT REV HCPCS COMBO 1, 59.50,OTHER, 26.12, 106.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19755,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 46.92,,OUTPAT REV HCPCS COMBO 1, 59.50,OTHER, 26.12, 106.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19756,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 78.68,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19757,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 47.36,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19758,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 47.36,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19759,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 52.89,,OUTPAT REV HCPCS COMBO 1, 66.70,OTHER, 27.86, 120.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19760,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 52.89,,OUTPAT REV HCPCS COMBO 1, 66.70,OTHER, 27.86, 120.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19761,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 33.97,,OUTPAT REV HCPCS COMBO 1, 43.51,OTHER, 20.72, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19762,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 38.00,,OUTPAT REV HCPCS COMBO 1, 47.68,OTHER, 19.00, 86.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19763,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.58,,OUTPAT REV HCPCS COMBO 1, 58.39,OTHER, 27.86, 103.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19764,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 64.05,,OUTPAT REV HCPCS COMBO 1, 77.47,OTHER, 19.86, 145.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19765,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 50.90,,OUTPAT REV HCPCS COMBO 1, 62.50,OTHER, 19.74, 116.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19766,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 37.53,,OUTPAT REV HCPCS COMBO 1, 46.75,OTHER, 17.35, 85.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19767,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.68,,OUTPAT REV HCPCS COMBO 1, 41.14,OTHER, 16.94, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19768,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 55.83,,OUTPAT REV HCPCS COMBO 1, 67.08,OTHER, 15.47, 127.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19769,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 40.75,,OUTPAT REV HCPCS COMBO 1, 50.52,OTHER, 17.84, 92.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19770,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 21.41,,OUTPAT REV HCPCS COMBO 1, 28.18,OTHER, 16.21, 48.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19771,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 42.33,,OUTPAT REV HCPCS COMBO 1, 52.54,OTHER, 18.79, 96.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19772,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 42.33,,OUTPAT REV HCPCS COMBO 1, 52.54,OTHER, 18.79, 96.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19773,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 41.16,OTHER, 19.07, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19774,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.26,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19775,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.26,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19776,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.26,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19777,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 37.52,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19778,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 38.81,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19779,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 38.81,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19780,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 39.49,,OUTPAT REV HCPCS COMBO 1, 49.38,OTHER, 19.07, 89.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19781,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 66.65,,OUTPAT REV HCPCS COMBO 1, 80.11,OTHER, 18.55, 151.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19782,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 66.65,,OUTPAT REV HCPCS COMBO 1, 80.11,OTHER, 18.55, 151.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19783,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 314.67,,OUTPAT REV HCPCS COMBO 1, 361.76,OTHER, 18.55, 717.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19784,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 138.03,,OUTPAT REV HCPCS COMBO 1, 161.64,OTHER, 20.54, 314.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19785,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 120.30,,OUTPAT REV HCPCS COMBO 1, 158.63,OTHER, 92.44, 274.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19786,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 120.30,,OUTPAT REV HCPCS COMBO 1, 158.63,OTHER, 92.44, 274.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19787,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.75,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19788,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.75,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19789,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.75,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19790,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 102.77,,OUTPAT REV HCPCS COMBO 1, 152.44,OTHER, 102.77, 234.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19791,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19792,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19793,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19794,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19795,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19796,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19797,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19798,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19799,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 127.76,,OUTPAT REV HCPCS COMBO 1, 146.86,OTHER, 7.46, 291.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19800,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 47.30,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19801,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 47.30,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19802,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 47.30,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19803,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 39.16,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19804,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 37.22,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19805,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 39.16,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19806,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19807,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19808,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 168.35,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19809,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 59.99,,OUTPAT REV HCPCS COMBO 1, 70.78,OTHER, 11.16, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19810,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 59.99,,OUTPAT REV HCPCS COMBO 1, 70.78,OTHER, 11.16, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19811,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19812,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19813,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19814,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19815,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19816,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19817,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 59.99,,OUTPAT REV HCPCS COMBO 1, 76.50,OTHER, 35.20, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19818,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 112.23,,OUTPAT REV HCPCS COMBO 1, 149.18,OTHER, 91.25, 255.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19819,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 68.57,,OUTPAT REV HCPCS COMBO 1, 81.41,OTHER, 14.86, 156.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19820,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 68.57,,OUTPAT REV HCPCS COMBO 1, 81.41,OTHER, 14.86, 156.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19821,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 24.24,,OUTPAT REV HCPCS COMBO 1, 30.76,OTHER, 13.60, 55.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19822,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 61.36,,OUTPAT REV HCPCS COMBO 1, 72.64,OTHER, 12.41, 139.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19823,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 61.36,,OUTPAT REV HCPCS COMBO 1, 72.64,OTHER, 12.41, 139.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19824,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 66.06,,OUTPAT REV HCPCS COMBO 1, 78.26,OTHER, 13.63, 150.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19825,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 66.06,,OUTPAT REV HCPCS COMBO 1, 78.26,OTHER, 13.63, 150.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19826,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 67.12,,OUTPAT REV HCPCS COMBO 1, 78.99,OTHER, 11.64, 152.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19827,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 38.75,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19828,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 38.75,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19829,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 38.75,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19830,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 34.07,,OUTPAT REV HCPCS COMBO 1, 40.96,OTHER, 9.55, 77.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19831,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.91,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19832,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.91,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19833,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.91,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19834,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 70.00,,OUTPAT REV HCPCS COMBO 1, 82.26,OTHER, 11.65, 159.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19835,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 70.00,,OUTPAT REV HCPCS COMBO 1, 82.26,OTHER, 11.65, 159.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19836,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 63.28,,OUTPAT REV HCPCS COMBO 1, 74.74,OTHER, 12.11, 144.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19837,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 76.88,,OUTPAT REV HCPCS COMBO 1, 91.00,OTHER, 15.55, 175.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19838,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 57.47,,OUTPAT REV HCPCS COMBO 1, 68.31,OTHER, 12.82, 130.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19839,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 14.19,,OUTPAT REV HCPCS COMBO 1, 17.74,OTHER, 6.84, 32.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19840,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 17.99,,OUTPAT REV HCPCS COMBO 1, 22.99,OTHER, 10.78, 40.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19841,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 24.94,,OUTPAT REV HCPCS COMBO 1, 29.95,OTHER, 6.84, 56.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19842,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 34.74,,OUTPAT REV HCPCS COMBO 1, 42.41,OTHER, 12.46, 79.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19843,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 24.33,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19844,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 22.66,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19845,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 22.66,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19846,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 22.74,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19847,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 22.74,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19848,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 31.96,,OUTPAT REV HCPCS COMBO 1, 38.14,OTHER, 7.76, 72.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19849,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 31.96,,OUTPAT REV HCPCS COMBO 1, 38.14,OTHER, 7.76, 72.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19850,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 23.16,,OUTPAT REV HCPCS COMBO 1, 28.29,OTHER, 8.38, 52.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19851,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.72,OTHER, 28.16, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19852,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 260.02,,OUTPAT REV HCPCS COMBO 1, 299.39,OTHER, 17.26, 592.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19853,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.69,,OUTPAT REV HCPCS COMBO 1, 40.67,OTHER, 14.88, 74.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19854,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 34.45,,OUTPAT REV HCPCS COMBO 1, 43.08,OTHER, 16.61, 78.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19855,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 102.77,,OUTPAT REV HCPCS COMBO 1, 121.25,OTHER, 19.08, 234.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19856,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.89,OTHER, 28.87, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19857,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19858,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19859,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19860,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19861,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19862,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 162.17,,OUTPAT REV HCPCS COMBO 1, 198.86,OTHER, 61.69, 369.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19863,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 162.17,,OUTPAT REV HCPCS COMBO 1, 198.86,OTHER, 61.69, 369.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19864,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 67.57,,OUTPAT REV HCPCS COMBO 1, 100.71,OTHER, 67.57, 153.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19865,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 182.09,,OUTPAT REV HCPCS COMBO 1, 221.47,OTHER, 61.69, 415.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19866,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 56.71,,OUTPAT REV HCPCS COMBO 1, 76.43,OTHER, 50.53, 129.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19867,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 207.69,,OUTPAT REV HCPCS COMBO 1, 265.03,OTHER, 122.54, 473.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19868,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19869,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 64.50,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19870,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 64.50,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19871,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 266.63,,OUTPAT REV HCPCS COMBO 1, 445.68,OTHER, 266.63, 607.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19872,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19873,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19874,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19875,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 160.23,,OUTPAT REV HCPCS COMBO 1, 193.99,OTHER, 50.53, 365.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19876,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 160.23,,OUTPAT REV HCPCS COMBO 1, 193.99,OTHER, 50.53, 365.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19877,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19878,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 142.33,,OUTPAT REV HCPCS COMBO 1, 173.66,OTHER, 50.53, 324.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19879,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.89,OTHER, 28.87, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19880,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 75.34,,OUTPAT REV HCPCS COMBO 1, 204.22,OTHER, 50.53, 599.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19881,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 263.13,,OUTPAT REV HCPCS COMBO 1, 204.22,OTHER, 50.53, 599.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19882,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 116.09,,OUTPAT REV HCPCS COMBO 1, 146.52,OTHER, 61.69, 264.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19883,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 116.09,,OUTPAT REV HCPCS COMBO 1, 146.52,OTHER, 61.69, 264.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19884,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 62.25,OTHER, 23.83, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19885,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 62.25,OTHER, 23.83, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19886,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 33.97,,OUTPAT REV HCPCS COMBO 1, 43.07,OTHER, 18.86, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19887,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 33.97,,OUTPAT REV HCPCS COMBO 1, 43.07,OTHER, 18.86, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19888,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 33.97,,OUTPAT REV HCPCS COMBO 1, 44.25,OTHER, 23.81, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19889,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 17.88,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19890,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 83.33,,OUTPAT REV HCPCS COMBO 1, 100.14,OTHER, 23.14, 189.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19891,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 627.37,,OUTPAT REV HCPCS COMBO 1, 800.72,OTHER, 370.73, 1429.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19892,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 627.37,,OUTPAT REV HCPCS COMBO 1, 800.72,OTHER, 370.73, 1429.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19893,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 59.91,OTHER, 38.32, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19894,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 59.91,OTHER, 38.32, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19895,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 238.65,,OUTPAT REV HCPCS COMBO 1, 294.34,OTHER, 97.97, 543.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19896,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19897,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19898,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 13.33,,OUTPAT REV HCPCS COMBO 1, 16.75,OTHER, 6.79, 30.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19899,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 13.33,,OUTPAT REV HCPCS COMBO 1, 16.75,OTHER, 6.79, 30.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19900,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 48.34,,OUTPAT REV HCPCS COMBO 1, 56.81,OTHER, 8.06, 110.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19901,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.99,,OUTPAT REV HCPCS COMBO 1, 39.98,OTHER, 10.56, 75.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19902,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 33.11,,OUTPAT REV HCPCS COMBO 1, 41.73,OTHER, 17.35, 75.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19903,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2550.94,,OUTPAT REV HCPCS COMBO 1, 3802.17,OTHER, 2550.94, 5813.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19904,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 48.44,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19905,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 48.44,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19906,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 12.69,,OUTPAT REV HCPCS COMBO 1, 23.30,OTHER, 12.69, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19907,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 25.59,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19908,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 12.79,,OUTPAT REV HCPCS COMBO 1, 23.42,OTHER, 12.79, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19909,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 55.47,,OUTPAT REV HCPCS COMBO 1, 82.68,OTHER, 55.47, 126.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19910,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19911,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.79,,OUTPAT REV HCPCS COMBO 1, 149.84,OTHER, 65.79, 315.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19912,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.79,,OUTPAT REV HCPCS COMBO 1, 149.84,OTHER, 65.79, 315.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19913,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 59.75,,OUTPAT REV HCPCS COMBO 1, 89.06,OTHER, 59.75, 136.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19914,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 21.50,,OUTPAT REV HCPCS COMBO 1, 41.40,OTHER, 21.50, 71.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19915,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 21.50,,OUTPAT REV HCPCS COMBO 1, 41.40,OTHER, 21.50, 71.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19916,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 255.16,,OUTPAT REV HCPCS COMBO 1, 356.50,OTHER, 255.16, 581.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19917,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 533.11,,OUTPAT REV HCPCS COMBO 1, 687.64,OTHER, 345.38, 1214.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19918,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 135.24,,OUTPAT REV HCPCS COMBO 1, 201.57,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19919,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19920,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19921,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.55,,OUTPAT REV HCPCS COMBO 1, 60.00,OTHER, 36.55, 83.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19922,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 22.12,,OUTPAT REV HCPCS COMBO 1, 36.74,OTHER, 22.12, 50.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19923,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 22.12,,OUTPAT REV HCPCS COMBO 1, 36.74,OTHER, 22.12, 50.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19924,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19925,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19926,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19927,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19928,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19929,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19930,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19931,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 34.29,,OUTPAT REV HCPCS COMBO 1, 51.11,OTHER, 34.29, 78.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19932,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 58.79,,OUTPAT REV HCPCS COMBO 1, 87.62,OTHER, 58.79, 133.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19933,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 58.79,,OUTPAT REV HCPCS COMBO 1, 87.62,OTHER, 58.79, 133.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19934,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19935,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 67.85,,OUTPAT REV HCPCS COMBO 1, 111.30,OTHER, 67.85, 154.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19936,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 67.85,,OUTPAT REV HCPCS COMBO 1, 111.30,OTHER, 67.85, 154.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19937,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19938,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19939,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 73.49,,OUTPAT REV HCPCS COMBO 1, 104.75,OTHER, 73.49, 167.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19940,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 73.49,,OUTPAT REV HCPCS COMBO 1, 104.75,OTHER, 73.49, 167.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19941,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 4.30,,OUTPAT REV HCPCS COMBO 1, 12.78,OTHER, 4.30, 33.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19942,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 14.22,,OUTPAT REV HCPCS COMBO 1, 17.36,OTHER, 5.09, 32.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19943,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 130.68,,OUTPAT REV HCPCS COMBO 1, 184.48,OTHER, 130.68, 297.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19944,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 146.42,,OUTPAT REV HCPCS COMBO 1, 202.35,OTHER, 146.42, 333.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19945,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 63.61,,OUTPAT REV HCPCS COMBO 1, 99.37,OTHER, 63.61, 144.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19946,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.39,,OUTPAT REV HCPCS COMBO 1, 88.44,OTHER, 59.56, 149.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19947,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 84.22,,OUTPAT REV HCPCS COMBO 1, 131.72,OTHER, 84.22, 191.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19948,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 82.81,,OUTPAT REV HCPCS COMBO 1, 117.05,OTHER, 82.81, 188.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19949,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 126.51,,OUTPAT REV HCPCS COMBO 1, 179.75,OTHER, 126.51, 288.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19950,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 109.46,,OUTPAT REV HCPCS COMBO 1, 158.52,OTHER, 109.46, 249.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19951,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 132.20,,OUTPAT REV HCPCS COMBO 1, 186.21,OTHER, 132.20, 301.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19952,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 63.26,,OUTPAT REV HCPCS COMBO 1, 83.96,OTHER, 50.93, 144.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19953,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 102.00,,OUTPAT REV HCPCS COMBO 1, 167.44,OTHER, 102.00, 232.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19954,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 106.26,,OUTPAT REV HCPCS COMBO 1, 172.28,OTHER, 106.26, 242.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19955,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 25.59,,OUTPAT REV HCPCS COMBO 1, 49.86,OTHER, 25.59, 87.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19956,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 106.61,,OUTPAT REV HCPCS COMBO 1, 141.43,OTHER, 85.51, 242.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19957,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.42,,OUTPAT REV HCPCS COMBO 1, 69.71,OTHER, 45.42, 103.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19958,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 120.47,,OUTPAT REV HCPCS COMBO 1, 177.65,OTHER, 120.47, 274.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19959,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 130.87,,OUTPAT REV HCPCS COMBO 1, 189.46,OTHER, 130.87, 298.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19960,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 210.54,,OUTPAT REV HCPCS COMBO 1, 279.93,OTHER, 171.54, 479.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19961,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 197.39,,OUTPAT REV HCPCS COMBO 1, 265.00,OTHER, 171.54, 449.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19962,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 108.18,,OUTPAT REV HCPCS COMBO 1, 149.90,OTHER, 108.18, 246.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19963,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 137.41,,OUTPAT REV HCPCS COMBO 1, 167.02,OTHER, 46.09, 313.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19964,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 57.35,,OUTPAT REV HCPCS COMBO 1, 76.10,OTHER, 46.09, 130.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19965,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 120.09,,OUTPAT REV HCPCS COMBO 1, 147.35,OTHER, 46.09, 273.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19966,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 174.02,,OUTPAT REV HCPCS COMBO 1, 227.22,OTHER, 124.32, 396.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19967,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 234.14,,OUTPAT REV HCPCS COMBO 1, 295.49,OTHER, 124.32, 533.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19968,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 74.67,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 74.67, 170.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19969,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 110.85,,OUTPAT REV HCPCS COMBO 1, 155.48,OTHER, 110.85, 252.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19970,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 17.18,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19971,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 17.18,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19972,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 17.18,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19973,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 8.41,,OUTPAT REV HCPCS COMBO 1, 36.72,OTHER, 8.41, 114.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19974,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 158.39,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 114.13, 360.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19975,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 158.39,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 114.13, 360.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19976,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 391.14,,OUTPAT REV HCPCS COMBO 1, 526.62,OTHER, 346.21, 891.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19977,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19978,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19979,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 132.44,,OUTPAT REV HCPCS COMBO 1, 162.12,OTHER, 49.24, 301.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19980,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 106.64,,OUTPAT REV HCPCS COMBO 1, 140.39,OTHER, 80.99, 243.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19981,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 106.64,,OUTPAT REV HCPCS COMBO 1, 140.39,OTHER, 80.99, 243.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19982,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 136.31,,OUTPAT REV HCPCS COMBO 1, 166.97,OTHER, 51.13, 310.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19983,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 37.67,,OUTPAT REV HCPCS COMBO 1, 54.96,OTHER, 37.67, 85.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19984,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.39,,OUTPAT REV HCPCS COMBO 1, 86.43,OTHER, 51.13, 149.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19985,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 699.47,,OUTPAT REV HCPCS COMBO 1, 950.56,OTHER, 656.16, 1594.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19986,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19987,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 399.90,,OUTPAT REV HCPCS COMBO 1, 545.72,OTHER, 384.68, 911.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19988,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 399.90,,OUTPAT REV HCPCS COMBO 1, 545.72,OTHER, 384.68, 911.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19989,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19990,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19991,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 473.98,,OUTPAT REV HCPCS COMBO 1, 591.97,OTHER, 225.62, 1080.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19992,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19993,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 200.25,,OUTPAT REV HCPCS COMBO 1, 250.40,OTHER, 96.59, 456.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19994,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 200.25,,OUTPAT REV HCPCS COMBO 1, 250.40,OTHER, 96.59, 456.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19995,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19996,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 449.04,,OUTPAT REV HCPCS COMBO 1, 563.65,OTHER, 225.62, 1023.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19997,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 19998,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 70.09,,OUTPAT REV HCPCS COMBO 1, 113.30,OTHER, 70.09, 159.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 19999,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 70.09,,OUTPAT REV HCPCS COMBO 1, 113.30,OTHER, 70.09, 159.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20000,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20001,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20002,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 215.00,,OUTPAT REV HCPCS COMBO 1, 297.88,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20003,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20004,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 201.13,,OUTPAT REV HCPCS COMBO 1, 262.11,OTHER, 141.55, 458.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20005,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 201.13,,OUTPAT REV HCPCS COMBO 1, 262.11,OTHER, 141.55, 458.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20006,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20007,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20008,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 545.87,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20009,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 545.87,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20010,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 383.08,OTHER, 225.62, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20011,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 545.87,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20012,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20013,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20014,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20015,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20016,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20017,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20018,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20019,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20020,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20021,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20022,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20023,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20024,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 529.82,,OUTPAT REV HCPCS COMBO 1, 655.39,OTHER, 225.62, 1207.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20025,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20026,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1114.13,,OUTPAT REV HCPCS COMBO 1, 1042.14,OTHER, 284.89, 2539.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20027,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 601.78,,OUTPAT REV HCPCS COMBO 1, 1042.14,OTHER, 284.89, 2539.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20028,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 187.48,,OUTPAT REV HCPCS COMBO 1, 184.77,OTHER, 39.56, 427.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20029,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 39.56,,OUTPAT REV HCPCS COMBO 1, 184.77,OTHER, 39.56, 427.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20030,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 452.95,,OUTPAT REV HCPCS COMBO 1, 547.41,OTHER, 138.71, 1032.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20031,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 154.36,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20032,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 154.36,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20033,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 125.79,,OUTPAT REV HCPCS COMBO 1, 199.86,OTHER, 125.79, 286.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20034,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 125.79,,OUTPAT REV HCPCS COMBO 1, 199.86,OTHER, 125.79, 286.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20035,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 263.32,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20036,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 345.29,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20037,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 379.26,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20038,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 263.32,,OUTPAT REV HCPCS COMBO 1, 332.46,OTHER, 140.42, 600.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20039,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 160.29,,OUTPAT REV HCPCS COMBO 1, 239.03,OTHER, 160.29, 365.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20040,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 160.29,,OUTPAT REV HCPCS COMBO 1, 239.03,OTHER, 160.29, 365.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20041,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 174.98,OTHER, 103.88, 239.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20042,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 136.10,OTHER, 76.16, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20043,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 74.39,,OUTPAT REV HCPCS COMBO 1, 140.33,OTHER, 74.39, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20044,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 182.75,,OUTPAT REV HCPCS COMBO 1, 228.33,OTHER, 87.35, 416.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20045,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 22.94,,OUTPAT REV HCPCS COMBO 1, 34.19,OTHER, 22.94, 52.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20046,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20047,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 140.89,,OUTPAT REV HCPCS COMBO 1, 182.46,OTHER, 94.34, 321.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20048,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 140.89,,OUTPAT REV HCPCS COMBO 1, 182.46,OTHER, 94.34, 321.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20049,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 61.67,,OUTPAT REV HCPCS COMBO 1, 125.89,OTHER, 61.67, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20050,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 61.67,,OUTPAT REV HCPCS COMBO 1, 125.89,OTHER, 61.67, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20051,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 316.56,,OUTPAT REV HCPCS COMBO 1, 415.63,OTHER, 235.80, 721.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20052,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1397.50,,OUTPAT REV HCPCS COMBO 1, 1853.96,OTHER, 1121.15, 3185.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20053,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1397.50,,OUTPAT REV HCPCS COMBO 1, 1853.96,OTHER, 1121.15, 3185.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20054,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1677.00,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20055,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1677.00,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20056,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1677.00,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20057,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 116.62,,OUTPAT REV HCPCS COMBO 1, 152.82,OTHER, 85.61, 265.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20058,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 127.40,,OUTPAT REV HCPCS COMBO 1, 165.98,OTHER, 89.47, 290.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20059,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 206.52,,OUTPAT REV HCPCS COMBO 1, 260.74,OTHER, 110.12, 470.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20060,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 206.52,,OUTPAT REV HCPCS COMBO 1, 260.74,OTHER, 110.12, 470.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20061,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 77.49,,OUTPAT REV HCPCS COMBO 1, 96.89,OTHER, 37.34, 176.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20062,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 77.49,,OUTPAT REV HCPCS COMBO 1, 96.89,OTHER, 37.34, 176.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20063,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 245.81,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20064,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 245.81,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20065,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 245.81,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20066,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 70.82,,OUTPAT REV HCPCS COMBO 1, 89.33,OTHER, 37.34, 161.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20067,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 70.85,,OUTPAT REV HCPCS COMBO 1, 89.33,OTHER, 37.34, 161.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20068,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 84.46,,OUTPAT REV HCPCS COMBO 1, 108.89,OTHER, 54.48, 192.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20069,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 84.46,,OUTPAT REV HCPCS COMBO 1, 108.89,OTHER, 54.48, 192.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20070,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 61.89,,OUTPAT REV HCPCS COMBO 1, 92.25,OTHER, 61.89, 141.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20071,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 61.89,,OUTPAT REV HCPCS COMBO 1, 92.25,OTHER, 61.89, 141.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20072,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 66.17,,OUTPAT REV HCPCS COMBO 1, 84.04,OTHER, 37.34, 150.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20073,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 66.17,,OUTPAT REV HCPCS COMBO 1, 84.04,OTHER, 37.34, 150.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20074,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 25.59,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20075,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 25.59,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20076,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 129.36,,OUTPAT REV HCPCS COMBO 1, 159.88,OTHER, 54.48, 294.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20077,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 129.36,,OUTPAT REV HCPCS COMBO 1, 159.88,OTHER, 54.48, 294.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20078,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 73.50,,OUTPAT REV HCPCS COMBO 1, 96.44,OTHER, 54.48, 167.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20079,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 73.50,,OUTPAT REV HCPCS COMBO 1, 96.44,OTHER, 54.48, 167.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20080,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 74.18,,OUTPAT REV HCPCS COMBO 1, 110.56,OTHER, 74.18, 169.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20081,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 74.18,,OUTPAT REV HCPCS COMBO 1, 110.56,OTHER, 74.18, 169.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20082,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 37.82,,OUTPAT REV HCPCS COMBO 1, 47.95,OTHER, 21.01, 86.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20083,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 37.82,,OUTPAT REV HCPCS COMBO 1, 47.95,OTHER, 21.01, 86.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20084,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 41.51,,OUTPAT REV HCPCS COMBO 1, 55.33,OTHER, 34.39, 94.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20085,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 41.51,,OUTPAT REV HCPCS COMBO 1, 55.33,OTHER, 34.39, 94.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20086,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.49,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20087,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.49,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20088,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.49,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20089,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 180.60,,OUTPAT REV HCPCS COMBO 1, 142.33,OTHER, 28.82, 411.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20090,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 57.99,,OUTPAT REV HCPCS COMBO 1, 142.33,OTHER, 28.82, 411.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20091,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 57.99,,OUTPAT REV HCPCS COMBO 1, 72.71,OTHER, 28.82, 132.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20092,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 52.84,,OUTPAT REV HCPCS COMBO 1, 74.33,OTHER, 52.80, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20093,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 52.80,,OUTPAT REV HCPCS COMBO 1, 74.33,OTHER, 52.80, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20094,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 52.84,,OUTPAT REV HCPCS COMBO 1, 74.35,OTHER, 52.84, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20095,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 56.36,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20096,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 56.36,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20097,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 56.36,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20098,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 40.91,,OUTPAT REV HCPCS COMBO 1, 60.80,OTHER, 40.91, 93.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20099,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 40.91,,OUTPAT REV HCPCS COMBO 1, 60.80,OTHER, 40.91, 93.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20100,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 29.08,,OUTPAT REV HCPCS COMBO 1, 47.68,OTHER, 29.08, 66.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20101,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 76.97,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20102,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 76.97,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20103,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 76.97,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20104,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 92.45,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20105,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 92.45,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20106,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 92.45,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20107,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 52.75,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20108,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 52.75,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20109,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 52.75,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20110,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 18.92,,OUTPAT REV HCPCS COMBO 1, 30.33,OTHER, 18.92, 43.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20111,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 113.97,,OUTPAT REV HCPCS COMBO 1, 178.52,OTHER, 113.97, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20112,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 135.24,,OUTPAT REV HCPCS COMBO 1, 202.67,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20113,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 128.04,,OUTPAT REV HCPCS COMBO 1, 194.50,OTHER, 128.04, 291.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20114,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 63.79,,OUTPAT REV HCPCS COMBO 1, 106.37,OTHER, 63.79, 145.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20115,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 109.36,,OUTPAT REV HCPCS COMBO 1, 173.75,OTHER, 109.36, 249.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20116,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 115.60,,OUTPAT REV HCPCS COMBO 1, 180.83,OTHER, 115.60, 263.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20117,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 136.43,,OUTPAT REV HCPCS COMBO 1, 204.49,OTHER, 136.43, 310.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20118,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.89,,OUTPAT REV HCPCS COMBO 1, 108.91,OTHER, 65.89, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20119,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 51.91,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20120,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 51.91,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20121,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 51.91,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20122,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 31.56,,OUTPAT REV HCPCS COMBO 1, 44.69,OTHER, 31.56, 71.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20123,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 54.89,,OUTPAT REV HCPCS COMBO 1, 78.22,OTHER, 54.89, 125.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20124,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 54.89,,OUTPAT REV HCPCS COMBO 1, 78.22,OTHER, 54.89, 125.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20125,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 38.11,,OUTPAT REV HCPCS COMBO 1, 59.17,OTHER, 38.11, 86.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20126,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 49.88,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20127,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 49.88,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20128,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 49.88,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20129,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20130,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 61.82,,OUTPAT REV HCPCS COMBO 1, 93.12,OTHER, 61.82, 140.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20131,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 52.03,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 52.03, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20132,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 113.97,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 52.03, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20133,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 53.32,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20134,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 53.32,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20135,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 53.32,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20136,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20137,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20138,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 60.63,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20139,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20140,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 60.63,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20141,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20142,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20143,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 129.00,,OUTPAT REV HCPCS COMBO 1, 192.27,OTHER, 129.00, 294.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20144,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20145,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20146,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 145.27,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20147,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 63.96,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20148,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 63.96,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20149,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 108.39,,OUTPAT REV HCPCS COMBO 1, 161.56,OTHER, 108.39, 247.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20150,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 108.39,,OUTPAT REV HCPCS COMBO 1, 161.56,OTHER, 108.39, 247.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20151,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20152,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20153,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 211.26,,OUTPAT REV HCPCS COMBO 1, 314.88,OTHER, 211.26, 481.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20154,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 211.26,,OUTPAT REV HCPCS COMBO 1, 314.88,OTHER, 211.26, 481.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20155,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 20.47,,OUTPAT REV HCPCS COMBO 1, 30.51,OTHER, 20.47, 46.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20156,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 44.59,,OUTPAT REV HCPCS COMBO 1, 66.46,OTHER, 44.59, 101.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20157,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 44.59,,OUTPAT REV HCPCS COMBO 1, 66.46,OTHER, 44.59, 101.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20158,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 74.56,,OUTPAT REV HCPCS COMBO 1, 111.13,OTHER, 74.56, 169.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20159,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 74.56,,OUTPAT REV HCPCS COMBO 1, 111.13,OTHER, 74.56, 169.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20160,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 110.02,,OUTPAT REV HCPCS COMBO 1, 163.98,OTHER, 110.02, 250.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20161,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 110.02,,OUTPAT REV HCPCS COMBO 1, 163.98,OTHER, 110.02, 250.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20162,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 147.30,,OUTPAT REV HCPCS COMBO 1, 219.55,OTHER, 147.30, 335.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20163,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 147.30,,OUTPAT REV HCPCS COMBO 1, 219.55,OTHER, 147.30, 335.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20164,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20165,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20166,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20167,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20168,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20169,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 115.64,,OUTPAT REV HCPCS COMBO 1, 149.74,OTHER, 77.35, 263.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20170,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 115.64,,OUTPAT REV HCPCS COMBO 1, 149.74,OTHER, 77.35, 263.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20171,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20172,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20173,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 178.88,,OUTPAT REV HCPCS COMBO 1, 233.57,OTHER, 127.82, 407.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20174,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 178.88,,OUTPAT REV HCPCS COMBO 1, 233.57,OTHER, 127.82, 407.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20175,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20176,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20177,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 282.66,,OUTPAT REV HCPCS COMBO 1, 369.55,OTHER, 203.96, 644.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20178,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 282.66,,OUTPAT REV HCPCS COMBO 1, 369.55,OTHER, 203.96, 644.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20179,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20180,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20181,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 443.36,,OUTPAT REV HCPCS COMBO 1, 580.80,OTHER, 324.71, 1010.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20182,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 443.36,,OUTPAT REV HCPCS COMBO 1, 580.80,OTHER, 324.71, 1010.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20183,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20184,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20185,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 739.51,,OUTPAT REV HCPCS COMBO 1, 954.02,OTHER, 479.76, 1685.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20186,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 739.51,,OUTPAT REV HCPCS COMBO 1, 954.02,OTHER, 479.76, 1685.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20187,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20188,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1182.84,,OUTPAT REV HCPCS COMBO 1, 1514.86,OTHER, 720.78, 2695.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20189,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 433.62,,OUTPAT REV HCPCS COMBO 1, 646.30,OTHER, 433.62, 988.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20190,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 19.23,OTHER, 12.90, 29.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20191,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 72.00,,OUTPAT REV HCPCS COMBO 1, 107.32,OTHER, 72.00, 164.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20192,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 72.00,,OUTPAT REV HCPCS COMBO 1, 107.32,OTHER, 72.00, 164.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20193,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 113.31,,OUTPAT REV HCPCS COMBO 1, 167.97,OTHER, 113.31, 258.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20194,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 118.06,,OUTPAT REV HCPCS COMBO 1, 173.37,OTHER, 118.06, 269.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20195,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 123.17,,OUTPAT REV HCPCS COMBO 1, 179.18,OTHER, 123.17, 280.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20196,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 139.26,,OUTPAT REV HCPCS COMBO 1, 197.44,OTHER, 139.26, 317.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20197,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 135.24,,OUTPAT REV HCPCS COMBO 1, 192.88,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20198,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 156.07,,OUTPAT REV HCPCS COMBO 1, 232.62,OTHER, 156.07, 355.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20199,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20200,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 101.97,,OUTPAT REV HCPCS COMBO 1, 155.10,OTHER, 101.97, 232.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20201,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 108.92,,OUTPAT REV HCPCS COMBO 1, 162.99,OTHER, 108.92, 248.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20202,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 118.79,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20203,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 118.79,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20204,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 118.79,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20205,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 121.35,,OUTPAT REV HCPCS COMBO 1, 177.10,OTHER, 121.35, 276.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20206,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 129.39,,OUTPAT REV HCPCS COMBO 1, 192.85,OTHER, 129.39, 294.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20207,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 139.26,,OUTPAT REV HCPCS COMBO 1, 207.56,OTHER, 139.26, 317.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20208,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 37.28,,OUTPAT REV HCPCS COMBO 1, 55.57,OTHER, 37.28, 84.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20209,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 63.96,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20210,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 30.10,,OUTPAT REV HCPCS COMBO 1, 44.86,OTHER, 30.10, 68.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20211,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 114.40,,OUTPAT REV HCPCS COMBO 1, 170.52,OTHER, 114.40, 260.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20212,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 22.74,,OUTPAT REV HCPCS COMBO 1, 33.14,OTHER, 22.74, 51.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20213,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.14,,OUTPAT REV HCPCS COMBO 1, 39.28,OTHER, 28.14, 64.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20214,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 40.58,,OUTPAT REV HCPCS COMBO 1, 60.49,OTHER, 40.58, 92.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20215,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 9.46,,OUTPAT REV HCPCS COMBO 1, 14.10,OTHER, 9.46, 21.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20216,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 9.46,,OUTPAT REV HCPCS COMBO 1, 54.72,OTHER, 9.46, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20217,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 63.96,,OUTPAT REV HCPCS COMBO 1, 54.72,OTHER, 9.46, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20218,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 109.65,,OUTPAT REV HCPCS COMBO 1, 148.65,OTHER, 101.33, 249.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20219,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 118.25,,OUTPAT REV HCPCS COMBO 1, 166.04,OTHER, 118.25, 269.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20220,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 5.48,,OUTPAT REV HCPCS COMBO 1, 8.17,OTHER, 5.48, 12.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20221,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 5.48,,OUTPAT REV HCPCS COMBO 1, 8.17,OTHER, 5.48, 12.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20222,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 165.55,,OUTPAT REV HCPCS COMBO 1, 350.13,OTHER, 165.55, 680.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20223,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 165.55,,OUTPAT REV HCPCS COMBO 1, 350.13,OTHER, 165.55, 680.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20224,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 261.01,,OUTPAT REV HCPCS COMBO 1, 553.11,OTHER, 261.01, 1078.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20225,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 261.01,,OUTPAT REV HCPCS COMBO 1, 553.11,OTHER, 261.01, 1078.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20226,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 152.65,,OUTPAT REV HCPCS COMBO 1, 308.45,OTHER, 152.65, 567.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20227,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 152.65,,OUTPAT REV HCPCS COMBO 1, 308.45,OTHER, 152.65, 567.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20228,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 220.16,,OUTPAT REV HCPCS COMBO 1, 466.19,OTHER, 220.16, 907.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20229,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 220.16,,OUTPAT REV HCPCS COMBO 1, 466.19,OTHER, 220.16, 907.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20230,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 377.54,,OUTPAT REV HCPCS COMBO 1, 562.72,OTHER, 377.54, 860.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20231,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 377.54,,OUTPAT REV HCPCS COMBO 1, 562.72,OTHER, 377.54, 860.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20232,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 419.25,,OUTPAT REV HCPCS COMBO 1, 624.89,OTHER, 419.25, 955.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20233,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 419.25,,OUTPAT REV HCPCS COMBO 1, 624.89,OTHER, 419.25, 955.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20234,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 58.48,,OUTPAT REV HCPCS COMBO 1, 87.16,OTHER, 58.48, 133.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20235,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 27.52,,OUTPAT REV HCPCS COMBO 1, 41.02,OTHER, 27.52, 62.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20236,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20237,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1288.28,,OUTPAT REV HCPCS COMBO 1, 1648.47,OTHER, 779.04, 2936.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20238,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1288.28,,OUTPAT REV HCPCS COMBO 1, 1648.47,OTHER, 779.04, 2936.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20239,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1402.23,,OUTPAT REV HCPCS COMBO 1, 1777.88,OTHER, 779.04, 3195.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20240,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1402.23,,OUTPAT REV HCPCS COMBO 1, 1777.88,OTHER, 779.04, 3195.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20241,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20242,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20243,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20244,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1097.72,OTHER, 508.57, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20245,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1097.72,OTHER, 508.57, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20246,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1162.11,OTHER, 779.04, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20247,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1162.11,OTHER, 779.04, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20248,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 8.23,,OUTPAT REV HCPCS COMBO 1, 9.74,OTHER, 1.66, 18.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20249,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 48.44,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20250,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 11.82,OTHER, 2.58, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20251,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 38.74,,OUTPAT REV HCPCS COMBO 1, 57.75,OTHER, 38.74, 88.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20252,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 20.10,,OUTPAT REV HCPCS COMBO 1, 29.96,OTHER, 20.10, 45.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20253,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 71.08,,OUTPAT REV HCPCS COMBO 1, 88.75,OTHER, 33.71, 162.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20254,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 58.81,OTHER, 33.71, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20255,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 168.13,,OUTPAT REV HCPCS COMBO 1, 250.60,OTHER, 168.13, 383.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20256,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 231.89,OTHER, 165.06, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20257,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 231.89,OTHER, 165.06, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20258,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 18.28,,OUTPAT REV HCPCS COMBO 1, 35.44,OTHER, 18.28, 61.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20259,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 26.32,,OUTPAT REV HCPCS COMBO 1, 44.57,OTHER, 26.32, 61.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20260,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 29.24,,OUTPAT REV HCPCS COMBO 1, 43.58,OTHER, 29.24, 66.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20261,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20262,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 111.71,,OUTPAT REV HCPCS COMBO 1, 166.51,OTHER, 111.71, 254.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20263,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 40.32,,OUTPAT REV HCPCS COMBO 1, 60.10,OTHER, 40.32, 91.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20264,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 3.30,,OUTPAT REV HCPCS COMBO 1, 4.92,OTHER, 3.30, 7.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20265,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 3.20,,OUTPAT REV HCPCS COMBO 1, 4.77,OTHER, 3.20, 7.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20266,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 8.74,,OUTPAT REV HCPCS COMBO 1, 13.02,OTHER, 8.74, 19.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20267,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 90.30,,OUTPAT REV HCPCS COMBO 1, 134.59,OTHER, 90.30, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20268,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .91,,OUTPAT REV HCPCS COMBO 1, 1.36,OTHER, .91, 2.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20269,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1.41,,OUTPAT REV HCPCS COMBO 1, 2.10,OTHER, 1.41, 3.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20270,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 17.38,,OUTPAT REV HCPCS COMBO 1, 25.91,OTHER, 17.38, 39.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20271,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 62.40,,OUTPAT REV HCPCS COMBO 1, 93.00,OTHER, 62.40, 142.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20272,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .98,,OUTPAT REV HCPCS COMBO 1, 1.46,OTHER, .98, 2.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20273,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .69,,OUTPAT REV HCPCS COMBO 1, 1.03,OTHER, .69, 1.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20274,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 3.46,,OUTPAT REV HCPCS COMBO 1, 5.15,OTHER, 3.46, 7.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20275,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 7.69,,OUTPAT REV HCPCS COMBO 1, 11.46,OTHER, 7.69, 17.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20276,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2.94,,OUTPAT REV HCPCS COMBO 1, 4.38,OTHER, 2.94, 6.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20277,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1.72,,OUTPAT REV HCPCS COMBO 1, 2.56,OTHER, 1.72, 3.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20278,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 5.02,,OUTPAT REV HCPCS COMBO 1, 7.91,OTHER, 5.02, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20279,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 5.59,,OUTPAT REV HCPCS COMBO 1, 7.91,OTHER, 5.02, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20280,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 29.38,,OUTPAT REV HCPCS COMBO 1, 43.79,OTHER, 29.38, 66.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20281,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 15.45,,OUTPAT REV HCPCS COMBO 1, 23.02,OTHER, 15.45, 35.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20282,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 4.52,,OUTPAT REV HCPCS COMBO 1, 6.74,OTHER, 4.52, 10.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20283,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 3.49,,OUTPAT REV HCPCS COMBO 1, 5.20,OTHER, 3.49, 7.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20284,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 171.57,,OUTPAT REV HCPCS COMBO 1, 575.18,OTHER, 171.57, 1597.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20285,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 171.57,,OUTPAT REV HCPCS COMBO 1, 690.66,OTHER, 171.57, 2082.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20286,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 171.57,,OUTPAT REV HCPCS COMBO 1, 656.15,OTHER, 171.57, 1937.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20287,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 171.57,,OUTPAT REV HCPCS COMBO 1, 607.70,OTHER, 171.57, 1734.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20288,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 214.57,,OUTPAT REV HCPCS COMBO 1, 735.35,OTHER, 214.57, 2065.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20289,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 367.65,,OUTPAT REV HCPCS COMBO 1, 421.89,OTHER, 18.42, 837.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20290,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2.06,,OUTPAT REV HCPCS COMBO 1, 3.08,OTHER, 2.06, 4.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20291,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20292,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20293,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20294,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20295,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20296,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20297,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20298,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20299,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20300,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20301,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20302,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20303,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20304,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20305,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20306,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20307,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20308,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20309,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20310,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20311,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20312,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20313,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20314,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20315,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20316,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20317,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20318,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20319,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20320,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20321,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20322,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20323,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20324,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20325,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20326,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20327,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.69,,OUTPAT REV HCPCS COMBO 1, 62.01,OTHER, 42.53, 104.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20328,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 49.02,,OUTPAT REV HCPCS COMBO 1, 73.06,OTHER, 49.02, 111.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20329,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20330,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 215.00,,OUTPAT REV HCPCS COMBO 1, 320.46,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20331,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 18.06,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20332,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20333,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 15.05,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20334,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20335,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 11.61,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20336,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20337,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20338,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20339,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20340,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20341,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1.94,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20342,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20343,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20344,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20345,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 79.09,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20346,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20347,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 77.40,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20348,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 24.94,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20349,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 24.94,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20350,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 142.83,,OUTPAT REV HCPCS COMBO 1, 212.89,OTHER, 142.83, 325.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20351,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 52.37,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20352,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20353,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 423.39,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20354,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 308.33,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20355,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 3.87,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20356,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20357,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20358,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20359,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20360,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20361,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20362,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20363,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20364,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20365,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20366,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 43.86,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20367,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 30.89,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20368,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 30.89,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20369,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20370,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 59.16,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20371,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20372,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20373,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20374,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20375,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 7.74,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20376,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 10.32,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20377,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20378,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 12.26,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20379,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 12.26,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20380,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20381,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20382,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20383,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20384,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20385,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20386,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 19.99,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20387,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 4.30,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20388,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 2.02,OTHER, 1.35, 3.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20389,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 215.43,,OUTPAT REV HCPCS COMBO 1, 321.10,OTHER, 215.43, 490.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20390,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 245.96,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20391,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20392,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20393,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20394,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20395,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20396,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20397,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20398,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 14.63,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20399,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 65.44,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20400,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 61.34,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20401,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 40.07,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20402,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 36.78,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20403,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 111.92,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20404,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 3270.45,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20405,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 19.44,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20406,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20407,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20408,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20409,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20410,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20411,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20412,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 1032.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20413,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20414,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20415,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20416,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20417,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20418,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20419,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 602.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20420,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 602.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20421,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 602.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20422,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20423,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20424,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20425,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20426,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20427,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 28.87,,OUTPAT REV HCPCS COMBO 1, 43.03,OTHER, 28.87, 65.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20428,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 4.30,,OUTPAT REV HCPCS COMBO 1, 6.41,OTHER, 4.30, 9.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20429,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2494.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20430,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2064.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20431,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2064.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20432,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, 2064.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20433,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20434,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20435,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20436,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20437,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20438,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20439,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20440,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20441,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20442,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20443,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20444,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20445,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20446,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20447,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20448,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20449,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20450,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20451,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20452,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20453,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20454,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20455,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20456,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20457,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20458,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20459,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20460,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,MEDADV_UHC,UNITED HEALTHCARE MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 20461,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20462,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20463,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20464,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20465,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20466,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20467,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20468,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20469,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20470,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20471,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20472,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20473,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20474,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20475,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20476,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20477,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20478,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20479,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 271.70,OTHER, 142.76, 477.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20480,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 271.70,OTHER, 142.76, 477.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20481,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 168.89,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20482,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 171.36,OTHER, 103.33, 229.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20483,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 273.87,OTHER, 142.76, 481.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20484,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 276.81,OTHER, 142.76, 430.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20485,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 274.44,,CLAIM ADJUSTMENT 3, 242.16,OTHER, 155.70, 354.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20486,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 850.02,OTHER, 203.58, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20487,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1237.88,,CLAIM ADJUSTMENT 3, 667.92,OTHER, 193.86, 1237.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20488,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 274.44,,CLAIM ADJUSTMENT 3, 177.23,OTHER, 68.01, 274.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20489,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 267.92,,CLAIM ADJUSTMENT 3, 131.69,OTHER, 30.91, 267.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20490,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 116.49,OTHER, 56.08, 143.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20491,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 256.74,,CLAIM ADJUSTMENT 3, 405.48,OTHER, 256.74, 597.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20492,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20493,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 256.74,,CLAIM ADJUSTMENT 3, 216.69,OTHER, 107.31, 256.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20494,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20495,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 456.98,,CLAIM ADJUSTMENT 3, 233.68,OTHER, 60.50, 456.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20496,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 158.67,OTHER, 92.29, 204.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20497,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 112.58,OTHER, 70.21, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20498,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 125.44,OTHER, 81.25, 180.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20499,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 114.17,OTHER, 51.67, 151.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20500,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 122.15,OTHER, 60.94, 143.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20501,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 138.81,OTHER, 86.20, 205.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20502,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 117.21,OTHER, 74.19, 164.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20503,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 258.26,OTHER, 90.53, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20504,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 287.58,OTHER, 115.70, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20505,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 334.39,OTHER, 155.88, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20506,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 1514.68,OTHER, 804.50, 2338.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20507,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 1306.30,OTHER, 595.28, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20508,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 925.64,OTHER, 268.49, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20509,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 389.69,OTHER, 87.88, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20510,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 427.24,OTHER, 120.12, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20511,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 457.59,OTHER, 146.17, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20512,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 732.74,OTHER, 102.89, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20513,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1168.49,OTHER, 299.85, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20514,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 300.44,OTHER, 126.74, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20515,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 495.14,OTHER, 178.41, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20516,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 534.75,OTHER, 212.41, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20517,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 572.81,OTHER, 245.09, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20518,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 541.95,OTHER, 218.59, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20519,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 578.99,OTHER, 250.39, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20520,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 1505.88,OTHER, 766.62, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20521,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 646.89,OTHER, 308.68, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20522,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1242.56,OTHER, 363.44, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20523,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 513.14,OTHER, 193.86, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20524,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 520.86,OTHER, 200.49, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20525,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 694.73,OTHER, 349.75, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20526,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 947.76,OTHER, 287.48, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20527,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1393.28,OTHER, 492.83, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20528,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 56.01,OTHER, 24.73, 76.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20529,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 185.53,OTHER, 86.20, 331.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20530,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 97.29,OTHER, 57.09, 126.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20531,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 97.14,OTHER, 56.97, 126.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20532,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 57.02,OTHER, 22.52, 86.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20533,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 372.97,OTHER, 189.00, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20534,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1446.78,OTHER, 538.75, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20535,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1121.68,OTHER, 259.66, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20536,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 383.22,,CLAIM ADJUSTMENT 3, 278.63,OTHER, 165.01, 383.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20537,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 383.22,,CLAIM ADJUSTMENT 3, 427.61,OTHER, 296.20, 675.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20538,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 237.66,OTHER, 143.26, 408.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20539,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 253.66,OTHER, 143.26, 440.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20540,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 272.17,OTHER, 143.26, 477.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20541,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 251.39,OTHER, 143.26, 436.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20542,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 261.55,OTHER, 143.26, 400.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20543,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 264.56,OTHER, 143.26, 462.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20544,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 306.35,OTHER, 204.98, 467.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20545,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 548.12,OTHER, 309.01, 833.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20546,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 132.82,,CLAIM ADJUSTMENT 3, 300.52,OTHER, 132.82, 482.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20547,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 132.82,,CLAIM ADJUSTMENT 3, 293.08,OTHER, 132.82, 524.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20548,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 1023.77,OTHER, 309.01, 1906.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20549,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 498.22,OTHER, 309.01, 738.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20550,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 435.32,,CLAIM ADJUSTMENT 3, 1703.49,OTHER, 435.32, 3210.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20551,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 435.32,,CLAIM ADJUSTMENT 3, 601.46,OTHER, 382.87, 849.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20552,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2347.12,,CLAIM ADJUSTMENT 3, 2228.68,OTHER, 1193.64, 2648.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20553,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 2329.49,OTHER, 1296.54, 2877.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20554,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 274.44,,CLAIM ADJUSTMENT 3, 163.86,OTHER, 56.52, 274.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20555,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 200.99,OTHER, 145.30, 331.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20556,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 93.03,OTHER, 53.43, 118.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20557,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 43.50,,CLAIM ADJUSTMENT 3, 22.22,OTHER, 5.74, 43.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20558,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 224.77,OTHER, 146.61, 325.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20559,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 451.07,,CLAIM ADJUSTMENT 3, 251.63,OTHER, 77.72, 451.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20560,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2427.54,,CLAIM ADJUSTMENT 3, 1148.36,OTHER, 241.56, 2427.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20561,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2427.54,,CLAIM ADJUSTMENT 3, 1534.16,OTHER, 572.76, 2427.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20562,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 232.01,OTHER, 122.32, 271.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20563,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 124.43,OTHER, 57.02, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20564,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 120.23,OTHER, 53.32, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20565,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 130.25,OTHER, 62.14, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20566,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 130.25,OTHER, 62.14, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20567,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 5204.99,OTHER, 2293.79, 8355.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20568,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 932.84,OTHER, 274.68, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20569,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 424.57,OTHER, 162.56, 774.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20570,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 334.89,OTHER, 162.56, 594.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20571,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 470.23,,CLAIM ADJUSTMENT 3, 675.88,OTHER, 470.23, 1131.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20572,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 499.77,OTHER, 162.56, 925.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20573,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 499.77,OTHER, 162.56, 925.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20574,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 207.69,OTHER, 148.80, 339.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20575,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 207.69,OTHER, 148.80, 339.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20576,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 103.34,,CLAIM ADJUSTMENT 3, 176.70,OTHER, 103.34, 305.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20577,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 188.66,,CLAIM ADJUSTMENT 3, 596.69,OTHER, 188.66, 1107.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20578,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 188.66,,CLAIM ADJUSTMENT 3, 596.69,OTHER, 188.66, 1107.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20579,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 544.52,,CLAIM ADJUSTMENT 3, 1089.64,OTHER, 544.52, 1926.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20580,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20581,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20582,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20583,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20584,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20585,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20586,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 20.38,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20587,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20588,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 331.58,,CLAIM ADJUSTMENT 3, 579.04,OTHER, 331.58, 1003.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20589,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1095.12,,CLAIM ADJUSTMENT 3, 1525.88,OTHER, 974.17, 2161.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20590,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2484.68,,CLAIM ADJUSTMENT 3, 4097.24,OTHER, 2484.68, 6115.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20591,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2985.38,,CLAIM ADJUSTMENT 3, 4480.28,OTHER, 2930.90, 6504.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20592,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1095.12,,CLAIM ADJUSTMENT 3, 813.44,OTHER, 362.55, 1095.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20593,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1095.12,,CLAIM ADJUSTMENT 3, 4090.68,OTHER, 1095.12, 7048.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20594,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 26.22,,CLAIM ADJUSTMENT 3, 124.21,OTHER, 26.22, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20595,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 26.22,,CLAIM ADJUSTMENT 3, 124.21,OTHER, 26.22, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20596,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2414.09,,CLAIM ADJUSTMENT 3, 1187.28,OTHER, 279.09, 2414.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20597,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1685.72,,CLAIM ADJUSTMENT 3, 803.17,OTHER, 172.67, 1685.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20598,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1685.72,,CLAIM ADJUSTMENT 3, 1733.21,OTHER, 971.08, 2155.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20599,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 1757.99,OTHER, 857.80, 2765.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20600,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 477.65,OTHER, 147.05, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20601,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 497.71,OTHER, 164.28, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20602,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 1514.68,OTHER, 857.80, 2302.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20603,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 2013.65,OTHER, 857.80, 3252.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20604,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 549.67,OTHER, 208.88, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20605,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 578.48,OTHER, 233.61, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20606,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20607,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20608,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 625.15,,CLAIM ADJUSTMENT 3, 718.33,OTHER, 501.48, 1142.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20609,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20610,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2666.24,,CLAIM ADJUSTMENT 3, 1780.93,OTHER, 711.42, 2666.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20611,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 4593.88,,CLAIM ADJUSTMENT 3, 2411.76,OTHER, 661.96, 4593.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20612,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 566.36,,CLAIM ADJUSTMENT 3, 283.55,OTHER, 69.77, 566.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20613,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 566.36,,CLAIM ADJUSTMENT 3, 298.98,OTHER, 83.02, 566.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20614,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 906.71,,CLAIM ADJUSTMENT 3, 482.77,OTHER, 136.45, 906.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20615,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 603.90,OTHER, 244.65, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20616,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 652.77,OTHER, 286.60, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20617,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 754.11,OTHER, 373.59, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20618,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 716.04,OTHER, 340.92, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20619,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 701.64,OTHER, 328.55, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20620,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1148.80,,CLAIM ADJUSTMENT 3, 2366.55,OTHER, 1148.80, 3726.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20621,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1384.25,,CLAIM ADJUSTMENT 3, 623.49,OTHER, 110.84, 1384.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20622,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 198.06,,CLAIM ADJUSTMENT 3, 256.43,OTHER, 159.42, 353.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20623,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1384.25,,CLAIM ADJUSTMENT 3, 637.38,OTHER, 122.76, 1384.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20624,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2350.90,,CLAIM ADJUSTMENT 3, 982.61,OTHER, 122.76, 2350.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20625,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2085.61,,CLAIM ADJUSTMENT 3, 1507.20,OTHER, 654.45, 2085.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20626,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 3410.78,,CLAIM ADJUSTMENT 3, 3143.54,OTHER, 1652.91, 3668.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20627,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 4593.88,,CLAIM ADJUSTMENT 3, 2486.35,OTHER, 725.99, 4593.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20628,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 4593.88,,CLAIM ADJUSTMENT 3, 2559.90,OTHER, 789.14, 4593.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20629,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20630,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 539.71,,CLAIM ADJUSTMENT 3, 1667.02,OTHER, 539.71, 2808.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20631,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 3135.31,,CLAIM ADJUSTMENT 3, 1786.42,OTHER, 572.31, 3135.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20632,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5153.51,,CLAIM ADJUSTMENT 3, 3662.54,OTHER, 1564.15, 5153.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20633,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1963.90,,CLAIM ADJUSTMENT 3, 889.66,OTHER, 161.63, 1963.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20634,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 191.60,,CLAIM ADJUSTMENT 3, 242.39,OTHER, 173.27, 394.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20635,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 191.60,,CLAIM ADJUSTMENT 3, 242.39,OTHER, 173.27, 394.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20636,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2085.61,,CLAIM ADJUSTMENT 3, 2146.09,OTHER, 1202.92, 2669.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20637,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 377.59,,CLAIM ADJUSTMENT 3, 199.77,OTHER, 96.75, 377.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20638,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 657.86,,CLAIM ADJUSTMENT 3, 266.50,OTHER, 96.75, 657.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20639,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1965.95,,CLAIM ADJUSTMENT 3, 2146.91,OTHER, 1478.34, 3369.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20640,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1965.95,,CLAIM ADJUSTMENT 3, 2146.91,OTHER, 1478.34, 3369.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20641,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20642,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20643,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20644,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 4781.78,,CLAIM ADJUSTMENT 3, 2579.17,OTHER, 748.07, 4781.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20645,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 146.68,,CLAIM ADJUSTMENT 3, 162.43,OTHER, 112.28, 255.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20646,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 146.68,,CLAIM ADJUSTMENT 3, 145.32,OTHER, 97.21, 221.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20647,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 191.60,,CLAIM ADJUSTMENT 3, 116.13,OTHER, 62.09, 191.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20648,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 76.24,OTHER, 51.17, 116.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20649,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 124.60,OTHER, 86.34, 208.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20650,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20651,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 62.55,OTHER, 36.98, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20652,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20653,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 99.80,OTHER, 58.91, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20654,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20655,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 161.46,OTHER, 113.20, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20656,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20657,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 62.55,OTHER, 36.98, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20658,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20659,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 171.96,OTHER, 122.45, 279.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20660,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20661,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 127.74,OTHER, 86.34, 215.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20662,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20663,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 189.58,OTHER, 137.97, 314.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20664,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20665,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 116.92,OTHER, 84.85, 193.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20666,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20667,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 299.54,OTHER, 138.19, 535.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20668,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20669,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 221.04,OTHER, 138.19, 377.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20670,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20671,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 177.44,OTHER, 127.28, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20672,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20673,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 71.21,OTHER, 44.60, 101.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20674,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20675,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 193.56,OTHER, 86.34, 347.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20676,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20677,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 223.50,OTHER, 86.34, 407.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20678,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1313.91,OTHER, 283.82, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20679,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1313.91,OTHER, 283.82, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20680,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20681,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20682,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1196.04,OTHER, 432.18, 2193.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20683,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1196.04,OTHER, 432.18, 2193.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20684,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20685,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20686,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1545.39,OTHER, 485.27, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20687,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1545.39,OTHER, 485.27, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20688,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20689,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20690,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.20,OTHER, 283.82, 1781.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20691,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20692,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 691.35,OTHER, 432.18, 1180.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20693,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20694,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 887.08,OTHER, 485.27, 1548.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20695,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20696,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 901.22,OTHER, 283.82, 1673.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20697,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 901.22,OTHER, 283.82, 1673.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20698,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20699,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20700,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1055.93,OTHER, 432.18, 1912.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20701,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1302.68,OTHER, 432.18, 2407.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20702,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20703,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20704,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 513.03,OTHER, 350.02, 797.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20705,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20706,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1290.59,OTHER, 283.82, 2454.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20707,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20708,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1374.81,OTHER, 432.18, 2552.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20709,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20710,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1265.96,OTHER, 485.27, 2308.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20711,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20712,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1076.14,OTHER, 495.38, 1923.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20713,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1076.14,OTHER, 495.38, 1923.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20714,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1076.14,OTHER, 495.38, 1923.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20715,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20716,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20717,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20718,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1270.81,OTHER, 495.38, 2313.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20719,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20720,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1681.52,OTHER, 779.04, 3002.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20721,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20722,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1224.87,OTHER, 508.57, 2215.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20723,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20724,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 1324.21,OTHER, 616.91, 2362.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20725,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 438.95,OTHER, 187.68, 616.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20726,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1532.99,OTHER, 779.04, 2704.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20727,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20728,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1233.59,OTHER, 508.57, 2232.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20729,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20730,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 1256.33,OTHER, 616.91, 2226.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20731,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 438.95,OTHER, 187.68, 616.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20732,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1461.09,OTHER, 779.04, 2560.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20733,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20734,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1413.66,OTHER, 508.57, 2594.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20735,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20736,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2181.19,OTHER, 779.04, 4005.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20737,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2181.19,OTHER, 779.04, 4005.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20738,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20739,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20740,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20741,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20742,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20743,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20744,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20745,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20746,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20747,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20748,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20749,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20750,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20751,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20752,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20753,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20754,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 242.05,OTHER, 86.34, 444.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20755,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 243.52,OTHER, 86.34, 447.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20756,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20757,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20758,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 214.14,OTHER, 138.19, 363.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20759,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 240.03,OTHER, 138.19, 415.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20760,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20761,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20762,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 248.87,OTHER, 138.19, 433.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20763,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20764,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 165.10,OTHER, 86.34, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20765,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20766,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 62.55,OTHER, 36.98, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20767,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20768,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1211.40,OTHER, 283.82, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20769,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1211.40,OTHER, 283.82, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20770,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1211.40,OTHER, 283.82, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20771,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20772,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20773,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1356.87,OTHER, 432.18, 2737.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20774,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1356.87,OTHER, 432.18, 2737.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20775,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20776,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1817.25,OTHER, 485.27, 3415.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20777,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20778,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 1171.85,OTHER, 117.71, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20779,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 1171.85,OTHER, 117.71, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20780,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 1171.85,OTHER, 117.71, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20781,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 209.22,OTHER, 117.71, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20782,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 209.22,OTHER, 117.71, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20783,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 209.22,OTHER, 117.71, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20784,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20785,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20786,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20787,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20788,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20789,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20790,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20791,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20792,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20793,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20794,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20795,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20796,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20797,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.01,OTHER, 86.34, 297.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20798,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.01,OTHER, 86.34, 297.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20799,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20800,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20801,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 247.65,OTHER, 138.19, 430.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20802,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20803,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 350.60,OTHER, 138.19, 637.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20804,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20805,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 382.63,OTHER, 138.19, 701.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20806,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20807,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 293.50,OTHER, 138.19, 522.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20808,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20809,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 265.86,OTHER, 138.19, 467.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20810,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20811,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 161.46,OTHER, 113.20, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20812,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20813,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 142.64,OTHER, 86.34, 245.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20814,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20815,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 63.06,OTHER, 36.98, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20816,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 163.44,OTHER, 113.20, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20817,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 96.05,OTHER, 37.54, 146.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20818,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 259.24,OTHER, 138.19, 454.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20819,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20820,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 166.91,OTHER, 118.00, 268.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20821,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20822,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 407.08,OTHER, 138.19, 750.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20823,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20824,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1459.38,OTHER, 283.82, 2793.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20825,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1459.38,OTHER, 283.82, 2793.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20826,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1459.38,OTHER, 283.82, 2793.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20827,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20828,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20829,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20830,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 664.89,OTHER, 483.75, 1102.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20831,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20832,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1649.11,OTHER, 283.82, 3173.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20833,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1649.11,OTHER, 283.82, 3173.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20834,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20835,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20836,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1665.51,OTHER, 432.18, 3136.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20837,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20838,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1439.18,OTHER, 283.82, 2752.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20839,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20840,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1652.58,OTHER, 432.18, 3110.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20841,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20842,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1580.48,OTHER, 485.27, 2940.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20843,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20844,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1712.29,OTHER, 508.57, 3193.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20845,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20846,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1894.78,OTHER, 508.57, 3559.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20847,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20848,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1677.93,OTHER, 508.57, 3124.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20849,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20850,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2119.80,OTHER, 779.04, 3881.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20851,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20852,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2539.54,OTHER, 779.04, 4724.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20853,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20854,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2390.20,OTHER, 779.04, 4424.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20855,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20856,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20857,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20858,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20859,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 236.81,OTHER, 138.19, 409.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20860,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20861,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 193.87,OTHER, 138.19, 323.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20862,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20863,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1261.16,OTHER, 283.82, 2395.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20864,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1261.16,OTHER, 283.82, 2395.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20865,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20866,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20867,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1256.10,OTHER, 432.18, 2314.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20868,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20869,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 894.65,OTHER, 485.27, 1563.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20870,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20871,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1751.53,OTHER, 508.57, 3272.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20872,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20873,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2629.35,OTHER, 779.04, 4904.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20874,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20875,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20876,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20877,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20878,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20879,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20880,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 20881,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 164.19,OTHER, 86.34, 288.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20882,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20883,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 224.35,OTHER, 86.34, 408.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20884,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20885,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 208.71,OTHER, 86.34, 377.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20886,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 208.71,OTHER, 86.34, 377.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20887,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 215.71,OTHER, 86.34, 391.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20888,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20889,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20890,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20891,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 149.11,OTHER, 86.34, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20892,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 149.11,OTHER, 86.34, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20893,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 149.11,OTHER, 86.34, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20894,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20895,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20896,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20897,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 175.84,OTHER, 86.34, 311.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20898,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.06,OTHER, 86.34, 298.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20899,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.06,OTHER, 86.34, 298.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20900,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20901,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20902,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20903,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 235.06,OTHER, 138.19, 405.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20904,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 235.06,OTHER, 138.19, 405.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20905,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 240.36,OTHER, 138.19, 416.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20906,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20907,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20908,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20909,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 219.70,OTHER, 86.34, 399.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20910,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 214.45,OTHER, 86.34, 389.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20911,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 214.45,OTHER, 86.34, 389.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20912,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20913,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20914,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20915,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 206.56,OTHER, 86.34, 373.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20916,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 211.81,OTHER, 86.34, 383.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20917,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 206.56,OTHER, 86.34, 373.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20918,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20919,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20920,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20921,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 230.04,OTHER, 86.34, 420.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20922,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 223.50,OTHER, 86.34, 407.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20923,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20924,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20925,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20926,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 230.83,OTHER, 86.34, 421.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20927,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 230.83,OTHER, 86.34, 421.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20928,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 237.37,OTHER, 86.34, 435.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20929,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20930,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20931,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20932,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 99.80,OTHER, 58.91, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20933,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 125.68,OTHER, 81.70, 186.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20934,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 99.80,OTHER, 58.91, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20935,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20936,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20937,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20938,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 213.73,OTHER, 86.34, 387.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20939,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 207.73,OTHER, 86.34, 375.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20940,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 207.74,OTHER, 86.34, 375.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20941,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20942,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20943,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20944,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 238.18,OTHER, 86.34, 436.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20945,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 243.44,OTHER, 86.34, 447.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20946,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 238.18,OTHER, 86.34, 436.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20947,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20948,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20949,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20950,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 238.48,OTHER, 138.19, 412.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20951,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 231.94,OTHER, 138.19, 399.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20952,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 231.94,OTHER, 138.19, 399.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20953,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20954,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20955,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20956,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 220.36,OTHER, 86.34, 400.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20957,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 220.42,OTHER, 86.34, 401.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20958,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 225.67,OTHER, 86.34, 411.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20959,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20960,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20961,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20962,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20963,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 174.69,OTHER, 86.34, 309.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20964,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20965,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20966,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20967,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20968,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20969,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20970,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20971,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20972,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20973,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20974,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20975,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20976,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20977,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20978,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20979,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20980,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20981,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20982,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20983,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20984,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20985,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20986,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20987,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20988,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20989,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1061.06,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20990,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20991,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20992,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20993,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20994,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20995,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20996,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20997,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20998,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 20999,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21000,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21001,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21002,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21003,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21004,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21005,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21006,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21007,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21008,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21009,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21010,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21011,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21012,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21013,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21014,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21015,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21016,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21017,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1484.34,OTHER, 432.18, 2772.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21018,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1484.34,OTHER, 432.18, 2772.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21019,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21020,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21021,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21022,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21023,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21024,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21025,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21026,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1055.55,OTHER, 508.57, 1875.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21027,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21028,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1797.05,OTHER, 779.04, 3234.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21029,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1797.05,OTHER, 779.04, 3234.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21030,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1797.05,OTHER, 779.04, 3234.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21031,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21032,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21033,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21034,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21035,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21036,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21037,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21038,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21039,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21040,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21041,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21042,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21043,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21044,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21045,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21046,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21047,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21048,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21049,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21050,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21051,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21052,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21053,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21054,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21055,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21056,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21057,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21058,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21059,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21060,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21061,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21062,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21063,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21064,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21065,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21066,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1450.34,OTHER, 779.04, 2538.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21067,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1450.34,OTHER, 779.04, 2538.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21068,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21069,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21070,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21071,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21072,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21073,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21074,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 196.99,OTHER, 88.46, 353.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21075,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 196.99,OTHER, 88.46, 353.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21076,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 196.99,OTHER, 88.46, 353.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21077,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21078,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21079,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21080,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21081,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21082,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21083,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21084,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21085,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21086,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21087,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21088,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21089,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 234.40,OTHER, 146.51, 446.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21090,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 234.40,OTHER, 146.51, 446.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21091,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 96.05,OTHER, 37.54, 146.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21092,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 96.05,OTHER, 37.54, 146.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21093,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 202.98,OTHER, 88.46, 365.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21094,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 202.98,OTHER, 88.46, 365.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21095,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 208.23,OTHER, 88.46, 375.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21096,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21097,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21098,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21099,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 210.73,OTHER, 86.34, 381.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21100,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 204.73,OTHER, 86.34, 369.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21101,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 204.73,OTHER, 86.34, 369.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21102,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21103,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21104,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21105,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 269.16,OTHER, 138.19, 474.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21106,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 274.41,OTHER, 138.19, 484.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21107,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 269.16,OTHER, 138.19, 474.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21108,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21109,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21110,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21111,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 402.07,OTHER, 138.19, 740.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21112,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 395.36,OTHER, 138.19, 727.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21113,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 395.36,OTHER, 138.19, 727.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21114,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21115,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21116,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21117,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 153.37,OTHER, 86.34, 266.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21118,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21119,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 243.07,OTHER, 86.34, 446.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21120,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 237.82,OTHER, 86.34, 436.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21121,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 237.82,OTHER, 86.34, 436.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21122,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21123,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21124,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21125,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 74.90,OTHER, 36.98, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21126,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 74.90,OTHER, 36.98, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21127,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 116.89,OTHER, 73.96, 168.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21128,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21129,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21130,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21131,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 218.95,OTHER, 138.19, 373.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21132,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 218.95,OTHER, 138.19, 373.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21133,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 225.30,OTHER, 138.19, 386.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21134,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21135,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21136,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21137,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 243.37,OTHER, 138.19, 422.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21138,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 236.76,OTHER, 138.19, 409.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21139,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 236.76,OTHER, 138.19, 409.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21140,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21141,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21142,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21143,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 186.56,OTHER, 86.34, 333.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21144,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 186.56,OTHER, 86.34, 333.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21145,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21146,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21147,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 250.19,OTHER, 86.34, 460.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21148,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 244.84,OTHER, 86.34, 450.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21149,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 244.94,OTHER, 86.34, 450.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21150,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21151,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21152,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21153,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 134.33,OTHER, 86.34, 228.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21154,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 134.33,OTHER, 86.34, 228.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21155,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 134.33,OTHER, 86.34, 228.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21156,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21157,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21158,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21159,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21160,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21161,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21162,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21163,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21164,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21165,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21166,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21167,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 179.26,OTHER, 86.34, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21168,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21169,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21170,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21171,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21172,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21173,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21174,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21175,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21176,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21177,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21178,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21179,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21180,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21181,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21182,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21183,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21184,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1193.14,OTHER, 283.82, 2258.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21185,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21186,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21187,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21188,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21189,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21190,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21191,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21192,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21193,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21194,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21195,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21196,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21197,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21198,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21199,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21200,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21201,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21202,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21203,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21204,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21205,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21206,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21207,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21208,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21209,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1435.02,OTHER, 432.18, 2673.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21210,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1428.39,OTHER, 432.18, 2660.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21211,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1428.39,OTHER, 432.18, 2660.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21212,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21213,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21214,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21215,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21216,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21217,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21218,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21219,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21220,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21221,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 796.22,OTHER, 495.38, 1361.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21222,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 796.22,OTHER, 495.38, 1361.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21223,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21224,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21225,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21226,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21227,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21228,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21229,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21230,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21231,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21232,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21233,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21234,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21235,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21236,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21237,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1953.37,OTHER, 779.04, 3547.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21238,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1953.37,OTHER, 779.04, 3547.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21239,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21240,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21241,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21242,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21243,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21244,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21245,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21246,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21247,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21248,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21249,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21250,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21251,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21252,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21253,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21254,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21255,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21256,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21257,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21258,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21259,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21260,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21261,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21262,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21263,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21264,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21265,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21266,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21267,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21268,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21269,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21270,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21271,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21272,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21273,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21274,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21275,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21276,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21277,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21278,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21279,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21280,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21281,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 102.58,OTHER, 71.38, 162.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21282,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 102.58,OTHER, 71.38, 162.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21283,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21284,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21285,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 172.76,,CLAIM ADJUSTMENT 3, 83.13,OTHER, 36.98, 172.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21286,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 172.76,,CLAIM ADJUSTMENT 3, 105.42,OTHER, 37.54, 172.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21287,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 322.43,OTHER, 138.19, 581.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21288,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 322.43,OTHER, 138.19, 581.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21289,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21290,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21291,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1346.03,OTHER, 283.82, 2565.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21292,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21293,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1544.22,OTHER, 432.18, 2892.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21294,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21295,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1743.20,OTHER, 485.27, 3266.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21296,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21297,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 813.20,,CLAIM ADJUSTMENT 3, 3113.75,OTHER, 813.20, 5860.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21298,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 813.20,,CLAIM ADJUSTMENT 3, 473.04,OTHER, 156.77, 813.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21299,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1743.46,OTHER, 495.38, 3262.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21300,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21301,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 2609.45,OTHER, 276.02, 5105.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21302,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 2609.45,OTHER, 276.02, 5105.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21303,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 265.76,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21304,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 265.76,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21305,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 3021.78,OTHER, 426.91, 5860.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21306,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 3021.78,OTHER, 426.91, 5860.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21307,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 319.65,OTHER, 143.52, 426.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21308,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 319.65,OTHER, 143.52, 426.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21309,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 3385.13,OTHER, 475.94, 6566.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21310,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 3385.13,OTHER, 475.94, 6566.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21311,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 3385.13,OTHER, 475.94, 6566.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21312,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 337.16,OTHER, 143.52, 475.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21313,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 337.16,OTHER, 143.52, 475.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21314,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 337.16,OTHER, 143.52, 475.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21315,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1689.68,OTHER, 508.57, 3148.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21316,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1689.68,OTHER, 508.57, 3148.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21317,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21318,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21319,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1837.06,OTHER, 779.04, 3314.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21320,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21321,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21322,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21323,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21324,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21325,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21326,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 371.17,OTHER, 127.36, 684.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21327,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 371.17,OTHER, 127.36, 684.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21328,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 371.17,OTHER, 127.36, 684.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21329,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 89.21,OTHER, 37.54, 127.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21330,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 89.21,OTHER, 37.54, 127.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21331,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21332,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21333,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 248.14,OTHER, 166.15, 378.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21334,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 230.64,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21335,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 429.88,OTHER, 249.71, 743.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21336,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 132.91,OTHER, 37.54, 249.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21337,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1495.57,OTHER, 495.38, 2764.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21338,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1495.57,OTHER, 495.38, 2764.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21339,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21340,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21341,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21342,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21343,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 385.53,OTHER, 141.55, 706.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21344,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 385.53,OTHER, 141.55, 706.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21345,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 385.53,OTHER, 141.55, 706.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21346,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21347,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21348,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21349,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 286.59,OTHER, 90.89, 531.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21350,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21351,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 281.44,OTHER, 133.37, 501.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21352,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 281.44,OTHER, 133.37, 501.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21353,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 281.44,OTHER, 133.37, 501.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21354,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 288.12,OTHER, 133.37, 514.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21355,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21356,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21357,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21358,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21359,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 503.49,OTHER, 141.55, 942.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21360,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21361,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21362,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21363,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21364,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21365,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21366,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21367,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21368,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21369,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21370,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21371,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 163.97,,CLAIM ADJUSTMENT 3, 468.07,OTHER, 163.97, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21372,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 163.97,,CLAIM ADJUSTMENT 3, 200.02,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21373,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21374,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21375,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21376,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21377,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21378,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21379,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21380,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21381,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21382,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21383,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 414.50,OTHER, 141.55, 764.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21384,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21385,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 214.87,OTHER, 133.37, 367.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21386,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 163.37,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21387,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 408.73,OTHER, 141.55, 752.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21388,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21389,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 507.55,OTHER, 141.55, 950.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21390,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21391,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 775.60,OTHER, 90.89, 1513.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21392,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21393,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 290.56,OTHER, 133.37, 519.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21394,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21395,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.77,OTHER, 141.55, 774.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21396,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21397,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 471.58,OTHER, 141.55, 878.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21398,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 471.58,OTHER, 141.55, 878.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21399,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 471.58,OTHER, 141.55, 878.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21400,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21401,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21402,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21403,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 322.12,OTHER, 90.89, 613.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21404,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 322.12,OTHER, 90.89, 613.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21405,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21406,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21407,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 408.48,OTHER, 141.55, 752.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21408,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21409,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 813.95,OTHER, 137.10, 1568.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21410,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 526.64,OTHER, 137.10, 991.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21411,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 526.64,OTHER, 137.10, 991.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21412,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 190.42,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21413,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 190.42,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21414,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 190.42,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21415,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21416,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 300.33,OTHER, 133.37, 539.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21417,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21418,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21419,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21420,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21421,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21422,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21423,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21424,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21425,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21426,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21427,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21428,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21429,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21430,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21431,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21432,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21433,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21434,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21435,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21436,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21437,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21438,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21439,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21440,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21441,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21442,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21443,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21444,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21445,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 34.54,,CLAIM ADJUSTMENT 3, 78.82,OTHER, 21.15, 181.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21446,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21447,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21448,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21449,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21450,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21451,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21452,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21453,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21454,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 281.03,OTHER, 175.87, 480.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21455,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 281.03,OTHER, 175.87, 480.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21456,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 281.03,OTHER, 175.87, 480.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21457,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 198.15,OTHER, 99.36, 230.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21458,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 198.15,OTHER, 99.36, 230.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21459,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21460,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21461,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21462,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21463,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 235.21,OTHER, 81.44, 588.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21464,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 235.21,OTHER, 81.44, 588.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21465,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 235.21,OTHER, 81.44, 588.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21466,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21467,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21468,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21469,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21470,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21471,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21472,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21473,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 116.40,OTHER, 73.53, 167.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21474,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 70.96,OTHER, 18.55, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21475,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 232.03,,CLAIM ADJUSTMENT 3, 414.07,OTHER, 232.03, 720.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21476,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 158.67,OTHER, 84.28, 343.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21477,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 158.67,OTHER, 84.28, 343.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21478,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 59.28,OTHER, 18.55, 105.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21479,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 59.28,OTHER, 18.55, 105.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21480,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 42.36,,CLAIM ADJUSTMENT 3, 154.63,OTHER, 42.36, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21481,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 204.30,OTHER, 138.19, 343.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21482,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 70.96,OTHER, 18.55, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21483,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 660.83,OTHER, 156.82, 1251.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21484,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 660.83,OTHER, 156.82, 1251.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21485,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 171.75,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21486,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 171.75,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21487,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 533.81,OTHER, 206.35, 972.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21488,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 533.81,OTHER, 206.35, 972.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21489,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 189.44,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21490,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 189.44,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21491,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 320.35,,CLAIM ADJUSTMENT 3, 757.92,OTHER, 320.35, 1367.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21492,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 320.35,,CLAIM ADJUSTMENT 3, 230.15,OTHER, 99.36, 320.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21493,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 322.62,,CLAIM ADJUSTMENT 3, 899.81,OTHER, 322.62, 1651.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21494,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 322.62,,CLAIM ADJUSTMENT 3, 230.96,OTHER, 99.36, 322.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21495,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 548.80,,CLAIM ADJUSTMENT 3, 1092.65,OTHER, 548.80, 1930.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21496,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 548.80,,CLAIM ADJUSTMENT 3, 311.74,OTHER, 99.36, 548.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21497,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 864.03,OTHER, 423.08, 1531.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21498,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 266.84,OTHER, 99.36, 423.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21499,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 344.89,OTHER, 215.00, 490.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21500,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 266.84,OTHER, 99.36, 423.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21501,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 830.31,OTHER, 410.92, 1470.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21502,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 262.50,OTHER, 99.36, 410.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21503,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 1103.77,OTHER, 410.92, 2018.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21504,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 262.50,OTHER, 99.36, 410.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21505,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 1111.16,OTHER, 359.95, 2058.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21506,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 244.29,OTHER, 99.36, 359.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21507,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 624.07,OTHER, 359.95, 1080.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21508,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 244.29,OTHER, 99.36, 359.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21509,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 672.34,OTHER, 360.01, 1177.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21510,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21511,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 559.38,OTHER, 360.01, 950.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21512,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21513,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 1228.06,OTHER, 360.01, 2292.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21514,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21515,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 1294.05,OTHER, 360.01, 2425.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21516,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21517,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21518,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21519,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 1149.19,OTHER, 775.51, 1767.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21520,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 1149.19,OTHER, 775.51, 1767.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21521,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 518.51,OTHER, 99.36, 1127.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21522,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 518.51,OTHER, 99.36, 1127.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21523,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 2267.81,OTHER, 1127.76, 4012.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21524,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 518.51,OTHER, 99.36, 1127.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21525,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 815.01,OTHER, 444.92, 1423.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21526,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 815.01,OTHER, 444.92, 1423.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21527,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 274.64,OTHER, 99.36, 444.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21528,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 274.64,OTHER, 99.36, 444.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21529,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.54,,CLAIM ADJUSTMENT 3, 635.79,OTHER, 283.54, 1140.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21530,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 283.54,,CLAIM ADJUSTMENT 3, 217.00,OTHER, 99.36, 283.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21531,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 300.36,,CLAIM ADJUSTMENT 3, 984.09,OTHER, 300.36, 1831.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21532,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 300.36,,CLAIM ADJUSTMENT 3, 223.01,OTHER, 99.36, 300.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21533,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 443.12,,CLAIM ADJUSTMENT 3, 1050.06,OTHER, 443.12, 1895.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21534,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 443.12,,CLAIM ADJUSTMENT 3, 274.00,OTHER, 99.36, 443.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21535,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 742.64,,CLAIM ADJUSTMENT 3, 684.67,OTHER, 447.20, 1019.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21536,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 742.64,,CLAIM ADJUSTMENT 3, 380.97,OTHER, 99.36, 742.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21537,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 2685.69,OTHER, 1509.32, 4668.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21538,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 744.80,OTHER, 176.64, 1509.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21539,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 2768.70,OTHER, 1509.32, 4835.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21540,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 744.80,OTHER, 176.64, 1509.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21541,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.78,,CLAIM ADJUSTMENT 3, 34.30,OTHER, 19.78, 59.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21542,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.18,,CLAIM ADJUSTMENT 3, 32.49,OTHER, 12.18, 59.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21543,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21544,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 10.09,,CLAIM ADJUSTMENT 3, 70.69,OTHER, 10.09, 137.05,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21545,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 15.20,,CLAIM ADJUSTMENT 3, 122.16,OTHER, 15.20, 237.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21546,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.28,,CLAIM ADJUSTMENT 3, 97.60,OTHER, 19.28, 186.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21547,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.28,,CLAIM ADJUSTMENT 3, 97.60,OTHER, 19.28, 186.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21548,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.50,,CLAIM ADJUSTMENT 3, 83.55,OTHER, 12.50, 161.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21549,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.50,,CLAIM ADJUSTMENT 3, 83.55,OTHER, 12.50, 161.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21550,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 68.59,,CLAIM ADJUSTMENT 3, 155.85,OTHER, 68.59, 280.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21551,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.76,,CLAIM ADJUSTMENT 3, 78.98,OTHER, 11.76, 152.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21552,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 22.37,,CLAIM ADJUSTMENT 3, 69.30,OTHER, 22.37, 128.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21553,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 46.28,,CLAIM ADJUSTMENT 3, 229.30,OTHER, 46.28, 438.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21554,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 88.95,OTHER, 20.98, 172.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21555,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 88.95,OTHER, 20.98, 172.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21556,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.13,,CLAIM ADJUSTMENT 3, 53.39,OTHER, 19.13, 98.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21557,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.13,,CLAIM ADJUSTMENT 3, 53.39,OTHER, 19.13, 98.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21558,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.50,,CLAIM ADJUSTMENT 3, 80.17,OTHER, 19.50, 151.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21559,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 31.20,,CLAIM ADJUSTMENT 3, 54.61,OTHER, 31.20, 94.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21560,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 80.03,OTHER, 19.08, 151.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21561,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 79.17,OTHER, 19.08, 149.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21562,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.52,,CLAIM ADJUSTMENT 3, 63.95,OTHER, 9.52, 123.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21563,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 22.37,,CLAIM ADJUSTMENT 3, 28.28,OTHER, 20.21, 46.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21564,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 83.69,OTHER, 19.08, 158.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21565,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 22.03,,CLAIM ADJUSTMENT 3, 53.47,OTHER, 22.03, 96.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21566,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 79.81,OTHER, 19.08, 151.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21567,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.78,,CLAIM ADJUSTMENT 3, 44.64,OTHER, 19.78, 80.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21568,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.78,,CLAIM ADJUSTMENT 3, 145.91,OTHER, 19.78, 283.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21569,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.36,,CLAIM ADJUSTMENT 3, 64.76,OTHER, 20.36, 120.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21570,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.16,,CLAIM ADJUSTMENT 3, 121.34,OTHER, 17.16, 235.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21571,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.50,,CLAIM ADJUSTMENT 3, 84.76,OTHER, 19.50, 160.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21572,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 32.53,,CLAIM ADJUSTMENT 3, 134.69,OTHER, 32.53, 254.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21573,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 26.84,,CLAIM ADJUSTMENT 3, 90.91,OTHER, 26.84, 169.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21574,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 56.90,OTHER, 10.75, 186.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21575,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 56.90,OTHER, 10.75, 186.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21576,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 23.85,OTHER, 17.20, 39.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21577,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 23.85,OTHER, 17.20, 39.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21578,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21579,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21580,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21581,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21582,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21583,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21584,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21585,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21586,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21587,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21588,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21589,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21590,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21591,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21592,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21593,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21594,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21595,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21596,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21597,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 4.56,,CLAIM ADJUSTMENT 3, 34.88,OTHER, 4.56, 67.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21598,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 4.56,,CLAIM ADJUSTMENT 3, 34.88,OTHER, 4.56, 67.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21599,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 4.56,,CLAIM ADJUSTMENT 3, 34.88,OTHER, 4.56, 67.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21600,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 20.93,OTHER, 3.24, 40.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21601,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 20.93,OTHER, 3.24, 40.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21602,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 20.93,OTHER, 3.24, 40.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21603,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 7.12,OTHER, 3.24, 12.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21604,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 3.12,,CLAIM ADJUSTMENT 3, 8.07,OTHER, 3.12, 14.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21605,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 33.86,OTHER, 12.40, 62.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21606,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 33.86,OTHER, 12.40, 62.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21607,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 75.71,OTHER, 12.40, 146.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21608,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 75.71,OTHER, 12.40, 146.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21609,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 105.66,,CLAIM ADJUSTMENT 3, 145.60,OTHER, 105.66, 241.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21610,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 105.66,,CLAIM ADJUSTMENT 3, 145.60,OTHER, 105.66, 241.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21611,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 94.12,,CLAIM ADJUSTMENT 3, 262.66,OTHER, 94.12, 482.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21612,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 131.99,,CLAIM ADJUSTMENT 3, 428.98,OTHER, 131.99, 797.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21613,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21614,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21615,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 21616,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.50,,CLAIM ADJUSTMENT 3, 53.15,OTHER, 6.50, 103.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21617,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.76,,CLAIM ADJUSTMENT 3, 38.90,OTHER, 11.76, 72.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21618,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 55.61,,CLAIM ADJUSTMENT 3, 146.83,OTHER, 55.61, 268.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21619,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.13,,CLAIM ADJUSTMENT 3, 20.13,OTHER, 7.13, 37.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21620,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.13,,CLAIM ADJUSTMENT 3, 20.13,OTHER, 7.13, 37.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21621,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.21,,CLAIM ADJUSTMENT 3, 28.92,OTHER, 11.21, 52.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21622,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.21,,CLAIM ADJUSTMENT 3, 28.92,OTHER, 11.21, 52.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21623,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 8.33,,CLAIM ADJUSTMENT 3, 60.58,OTHER, 8.33, 117.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21624,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 8.33,,CLAIM ADJUSTMENT 3, 60.58,OTHER, 8.33, 117.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21625,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 50.88,OTHER, 13.98, 95.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21626,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.36,,CLAIM ADJUSTMENT 3, 71.06,OTHER, 19.36, 133.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21627,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.82,,CLAIM ADJUSTMENT 3, 109.86,OTHER, 20.82, 210.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21628,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.14,,CLAIM ADJUSTMENT 3, 80.16,OTHER, 24.14, 149.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21629,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.14,,CLAIM ADJUSTMENT 3, 80.16,OTHER, 24.14, 149.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21630,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 63.10,OTHER, 20.98, 116.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21631,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 63.10,OTHER, 20.98, 116.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21632,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.34,,CLAIM ADJUSTMENT 3, 50.79,OTHER, 9.34, 97.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21633,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.34,,CLAIM ADJUSTMENT 3, 50.79,OTHER, 9.34, 97.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21634,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 42.16,,CLAIM ADJUSTMENT 3, 100.38,OTHER, 42.16, 181.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21635,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 46.34,,CLAIM ADJUSTMENT 3, 121.92,OTHER, 46.34, 222.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21636,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 30.37,,CLAIM ADJUSTMENT 3, 50.20,OTHER, 30.37, 86.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21637,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 27.31,,CLAIM ADJUSTMENT 3, 116.31,OTHER, 27.31, 220.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21638,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 14.24,,CLAIM ADJUSTMENT 3, 49.78,OTHER, 14.24, 93.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21639,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 23.30,,CLAIM ADJUSTMENT 3, 63.44,OTHER, 23.30, 116.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21640,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.22,,CLAIM ADJUSTMENT 3, 36.36,OTHER, 7.22, 69.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21641,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.22,,CLAIM ADJUSTMENT 3, 36.36,OTHER, 7.22, 69.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21642,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.22,,CLAIM ADJUSTMENT 3, 33.07,OTHER, 7.22, 62.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21643,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.31,,CLAIM ADJUSTMENT 3, 19.33,OTHER, 6.31, 35.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21644,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.38,,CLAIM ADJUSTMENT 3, 33.34,OTHER, 6.38, 63.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21645,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 22.92,,CLAIM ADJUSTMENT 3, 56.73,OTHER, 22.92, 102.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21646,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 42.62,,CLAIM ADJUSTMENT 3, 126.67,OTHER, 42.62, 244.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21647,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 42.62,,CLAIM ADJUSTMENT 3, 126.67,OTHER, 42.62, 244.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21648,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 42.62,,CLAIM ADJUSTMENT 3, 126.67,OTHER, 42.62, 244.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21649,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 38.58,,CLAIM ADJUSTMENT 3, 123.66,OTHER, 38.58, 229.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21650,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.43,,CLAIM ADJUSTMENT 3, 34.08,OTHER, 7.43, 64.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21651,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.43,,CLAIM ADJUSTMENT 3, 34.08,OTHER, 7.43, 64.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21652,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.43,,CLAIM ADJUSTMENT 3, 34.08,OTHER, 7.43, 64.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21653,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.70,,CLAIM ADJUSTMENT 3, 69.24,OTHER, 19.70, 129.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21654,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 8.69,,CLAIM ADJUSTMENT 3, 49.97,OTHER, 8.69, 96.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21655,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.58,,CLAIM ADJUSTMENT 3, 44.47,OTHER, 18.58, 80.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21656,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.74,,CLAIM ADJUSTMENT 3, 65.14,OTHER, 17.74, 122.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21657,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 27.30,,CLAIM ADJUSTMENT 3, 87.25,OTHER, 27.30, 162.05,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21658,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 27.30,,CLAIM ADJUSTMENT 3, 87.25,OTHER, 27.30, 162.05,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21659,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.29,,CLAIM ADJUSTMENT 3, 59.01,OTHER, 24.29, 106.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21660,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 36.36,,CLAIM ADJUSTMENT 3, 127.93,OTHER, 36.36, 240.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21661,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 36.36,,CLAIM ADJUSTMENT 3, 127.93,OTHER, 36.36, 240.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21662,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 56.46,OTHER, 15.47, 105.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21663,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 8.28,,CLAIM ADJUSTMENT 3, 13.69,OTHER, 8.28, 23.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21664,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.87,,CLAIM ADJUSTMENT 3, 73.71,OTHER, 17.87, 139.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21665,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.06,,CLAIM ADJUSTMENT 3, 87.73,OTHER, 24.06, 164.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21666,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.06,,CLAIM ADJUSTMENT 3, 87.73,OTHER, 24.06, 164.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21667,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 23.47,,CLAIM ADJUSTMENT 3, 66.31,OTHER, 23.47, 121.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21668,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 23.47,,CLAIM ADJUSTMENT 3, 66.31,OTHER, 23.47, 121.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21669,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 34.69,,CLAIM ADJUSTMENT 3, 190.19,OTHER, 34.69, 365.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21670,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 34.69,,CLAIM ADJUSTMENT 3, 214.01,OTHER, 34.69, 412.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21671,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.37,,CLAIM ADJUSTMENT 3, 47.49,OTHER, 9.37, 90.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21672,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.37,,CLAIM ADJUSTMENT 3, 47.49,OTHER, 9.37, 90.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21673,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.28,,CLAIM ADJUSTMENT 3, 41.70,OTHER, 19.28, 74.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21674,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.63,,CLAIM ADJUSTMENT 3, 59.73,OTHER, 16.63, 111.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21675,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.37,,CLAIM ADJUSTMENT 3, 31.62,OTHER, 7.37, 59.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21676,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.37,,CLAIM ADJUSTMENT 3, 31.62,OTHER, 7.37, 59.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21677,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.37,,CLAIM ADJUSTMENT 3, 31.62,OTHER, 7.37, 59.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21678,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 39.11,OTHER, 7.46, 74.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21679,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 39.11,OTHER, 7.46, 74.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21680,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.62,,CLAIM ADJUSTMENT 3, 93.47,OTHER, 13.62, 181.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21681,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.62,,CLAIM ADJUSTMENT 3, 93.47,OTHER, 13.62, 181.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21682,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.97,,CLAIM ADJUSTMENT 3, 45.06,OTHER, 16.97, 82.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21683,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 76.21,OTHER, 9.31, 148.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21684,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 21.72,,CLAIM ADJUSTMENT 3, 72.23,OTHER, 21.72, 134.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21685,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 21.72,,CLAIM ADJUSTMENT 3, 72.23,OTHER, 21.72, 134.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21686,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 75.36,OTHER, 26.66, 138.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21687,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 75.36,OTHER, 26.66, 138.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21688,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 36.38,,CLAIM ADJUSTMENT 3, 127.42,OTHER, 36.38, 238.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21689,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 36.38,,CLAIM ADJUSTMENT 3, 127.42,OTHER, 36.38, 238.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21690,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 27.06,,CLAIM ADJUSTMENT 3, 93.87,OTHER, 27.06, 175.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21691,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 40.24,,CLAIM ADJUSTMENT 3, 135.49,OTHER, 40.24, 252.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21692,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 40.24,,CLAIM ADJUSTMENT 3, 135.49,OTHER, 40.24, 252.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21693,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 46.51,,CLAIM ADJUSTMENT 3, 83.83,OTHER, 46.51, 146.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21694,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 34.82,,CLAIM ADJUSTMENT 3, 73.72,OTHER, 34.82, 131.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21695,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 35.93,,CLAIM ADJUSTMENT 3, 75.45,OTHER, 35.93, 134.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21696,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 33.53,,CLAIM ADJUSTMENT 3, 121.64,OTHER, 33.53, 228.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21697,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.34,,CLAIM ADJUSTMENT 3, 69.17,OTHER, 7.34, 135.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21698,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.19,,CLAIM ADJUSTMENT 3, 124.67,OTHER, 24.19, 238.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21699,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.63,,CLAIM ADJUSTMENT 3, 76.46,OTHER, 19.63, 144.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21700,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 21.17,,CLAIM ADJUSTMENT 3, 71.48,OTHER, 21.17, 133.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21701,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21702,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21703,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21704,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21705,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21706,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 23.70,,CLAIM ADJUSTMENT 3, 64.96,OTHER, 23.70, 119.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21707,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.54,,CLAIM ADJUSTMENT 3, 34.98,OTHER, 11.54, 64.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21708,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.54,,CLAIM ADJUSTMENT 3, 203.52,OTHER, 37.54, 390.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21709,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 25.39,,CLAIM ADJUSTMENT 3, 61.71,OTHER, 25.39, 111.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21710,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 25.64,OTHER, 5.66, 48.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21711,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 25.64,OTHER, 5.66, 48.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21712,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 25.64,OTHER, 5.66, 48.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21713,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 28.32,OTHER, 5.66, 54.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21714,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 28.32,OTHER, 5.66, 54.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21715,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 28.32,OTHER, 5.66, 54.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21716,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 14.14,OTHER, 5.66, 25.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21717,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 64.46,OTHER, 6.84, 126.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21718,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 64.46,OTHER, 6.84, 126.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21719,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.97,,CLAIM ADJUSTMENT 3, 57.91,OTHER, 13.97, 109.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21720,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 10.37,,CLAIM ADJUSTMENT 3, 37.55,OTHER, 10.37, 70.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21721,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 26.76,,CLAIM ADJUSTMENT 3, 94.73,OTHER, 26.76, 177.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21722,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 26.76,,CLAIM ADJUSTMENT 3, 94.73,OTHER, 26.76, 177.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21723,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 94.52,OTHER, 26.66, 176.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21724,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 94.52,OTHER, 26.66, 176.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21725,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.12,,CLAIM ADJUSTMENT 3, 67.05,OTHER, 18.12, 125.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21726,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 31.62,,CLAIM ADJUSTMENT 3, 74.92,OTHER, 31.62, 135.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21727,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 48.30,OTHER, 13.98, 90.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21728,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 48.30,OTHER, 13.98, 90.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21729,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 48.30,OTHER, 13.98, 90.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21730,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 25.80,,CLAIM ADJUSTMENT 3, 99.83,OTHER, 25.80, 188.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21731,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21732,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21733,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21734,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21735,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21736,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21737,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.86,,CLAIM ADJUSTMENT 3, 128.28,OTHER, 24.86, 290.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21738,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.86,,CLAIM ADJUSTMENT 3, 128.28,OTHER, 24.86, 290.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21739,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.86,,CLAIM ADJUSTMENT 3, 128.28,OTHER, 24.86, 290.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21740,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 25.93,OTHER, 18.49, 42.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21741,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.46,,CLAIM ADJUSTMENT 3, 69.04,OTHER, 16.46, 130.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21742,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 43.88,OTHER, 9.31, 83.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21743,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 43.88,OTHER, 9.31, 83.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21744,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 43.88,OTHER, 9.31, 83.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21745,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21746,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21747,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21748,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21749,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.66,,CLAIM ADJUSTMENT 3, 70.04,OTHER, 16.66, 132.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21750,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 8.70,,CLAIM ADJUSTMENT 3, 51.00,OTHER, 8.70, 111.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21751,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 8.70,,CLAIM ADJUSTMENT 3, 51.00,OTHER, 8.70, 111.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21752,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.42,,CLAIM ADJUSTMENT 3, 85.45,OTHER, 18.42, 162.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21753,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 28.37,,CLAIM ADJUSTMENT 3, 68.77,OTHER, 28.37, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21754,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.44,,CLAIM ADJUSTMENT 3, 54.77,OTHER, 17.44, 101.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21755,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.44,,CLAIM ADJUSTMENT 3, 54.77,OTHER, 17.44, 101.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21756,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.92,,CLAIM ADJUSTMENT 3, 60.48,OTHER, 9.92, 116.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21757,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.92,,CLAIM ADJUSTMENT 3, 60.48,OTHER, 9.92, 116.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21758,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 66.68,,CLAIM ADJUSTMENT 3, 149.05,OTHER, 66.68, 267.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21759,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 49.24,,CLAIM ADJUSTMENT 3, 43.46,OTHER, 27.95, 63.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21760,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 15.12,,CLAIM ADJUSTMENT 3, 43.01,OTHER, 15.12, 79.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21761,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 15.12,,CLAIM ADJUSTMENT 3, 43.01,OTHER, 15.12, 79.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21762,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.65,,CLAIM ADJUSTMENT 3, 40.64,OTHER, 9.65, 76.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21763,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 34.72,,CLAIM ADJUSTMENT 3, 204.04,OTHER, 34.72, 392.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21764,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 23.41,,CLAIM ADJUSTMENT 3, 57.49,OTHER, 23.41, 104.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21765,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 159.56,OTHER, 24.40, 308.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21766,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 159.56,OTHER, 24.40, 308.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21767,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.60,,CLAIM ADJUSTMENT 3, 74.79,OTHER, 18.60, 163.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21768,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.60,,CLAIM ADJUSTMENT 3, 74.79,OTHER, 18.60, 163.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21769,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 56.53,,CLAIM ADJUSTMENT 3, 120.40,OTHER, 56.53, 214.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21770,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 56.53,,CLAIM ADJUSTMENT 3, 120.40,OTHER, 56.53, 214.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21771,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 30.54,,CLAIM ADJUSTMENT 3, 110.95,OTHER, 30.54, 208.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21772,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.52,,CLAIM ADJUSTMENT 3, 54.17,OTHER, 9.52, 104.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21773,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.82,,CLAIM ADJUSTMENT 3, 44.45,OTHER, 9.82, 84.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21774,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.82,,CLAIM ADJUSTMENT 3, 44.45,OTHER, 9.82, 84.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21775,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.81,,CLAIM ADJUSTMENT 3, 86.15,OTHER, 20.81, 162.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21776,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 59.45,,CLAIM ADJUSTMENT 3, 147.00,OTHER, 59.45, 266.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21777,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 59.45,,CLAIM ADJUSTMENT 3, 147.00,OTHER, 59.45, 266.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21778,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 27.89,,CLAIM ADJUSTMENT 3, 43.75,OTHER, 27.89, 74.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21779,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 28.27,,CLAIM ADJUSTMENT 3, 186.61,OTHER, 28.27, 361.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21780,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 45.87,OTHER, 7.46, 92.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21781,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 45.87,OTHER, 7.46, 92.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21782,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.83,,CLAIM ADJUSTMENT 3, 35.19,OTHER, 6.83, 67.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21783,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.83,,CLAIM ADJUSTMENT 3, 35.19,OTHER, 6.83, 67.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21784,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.85,,CLAIM ADJUSTMENT 3, 28.87,OTHER, 6.85, 54.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21785,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.82,,CLAIM ADJUSTMENT 3, 13.83,OTHER, 6.82, 24.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21786,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 21.01,,CLAIM ADJUSTMENT 3, 45.56,OTHER, 21.01, 81.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21787,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 30.04,,CLAIM ADJUSTMENT 3, 92.72,OTHER, 30.04, 171.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21788,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 30.04,,CLAIM ADJUSTMENT 3, 92.72,OTHER, 30.04, 171.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21789,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 39.19,,CLAIM ADJUSTMENT 3, 102.79,OTHER, 39.19, 187.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21790,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 27.91,,CLAIM ADJUSTMENT 3, 97.17,OTHER, 27.91, 181.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21791,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 26.48,,CLAIM ADJUSTMENT 3, 90.21,OTHER, 26.48, 174.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21792,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 26.48,,CLAIM ADJUSTMENT 3, 90.21,OTHER, 26.48, 174.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21793,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 26.48,,CLAIM ADJUSTMENT 3, 93.39,OTHER, 26.48, 174.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21794,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 24.66,OTHER, 5.28, 46.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21795,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 24.66,OTHER, 5.28, 46.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21796,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 57.84,OTHER, 5.28, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21797,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 57.84,OTHER, 5.28, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21798,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 57.84,OTHER, 5.28, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21799,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.76,,CLAIM ADJUSTMENT 3, 41.90,OTHER, 5.76, 83.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21800,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.76,,CLAIM ADJUSTMENT 3, 41.90,OTHER, 5.76, 83.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21801,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.76,,CLAIM ADJUSTMENT 3, 41.90,OTHER, 5.76, 83.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21802,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 144.06,OTHER, 15.47, 390.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21803,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 144.06,OTHER, 15.47, 390.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21804,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 25.68,,CLAIM ADJUSTMENT 3, 141.59,OTHER, 25.68, 394.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21805,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 25.68,,CLAIM ADJUSTMENT 3, 141.59,OTHER, 25.68, 394.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21806,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 38.44,,CLAIM ADJUSTMENT 3, 136.35,OTHER, 38.44, 255.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21807,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 40.46,,CLAIM ADJUSTMENT 3, 103.27,OTHER, 40.46, 187.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21808,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 31.67,,CLAIM ADJUSTMENT 3, 76.88,OTHER, 31.67, 139.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21809,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 29.15,,CLAIM ADJUSTMENT 3, 178.83,OTHER, 29.15, 344.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21810,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 31.30,,CLAIM ADJUSTMENT 3, 88.43,OTHER, 31.30, 162.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21811,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.92,,CLAIM ADJUSTMENT 3, 30.02,OTHER, 6.92, 56.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21812,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.92,,CLAIM ADJUSTMENT 3, 30.02,OTHER, 6.92, 56.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21813,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.28,,CLAIM ADJUSTMENT 3, 34.17,OTHER, 7.28, 88.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21814,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.28,,CLAIM ADJUSTMENT 3, 34.17,OTHER, 7.28, 88.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21815,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.28,,CLAIM ADJUSTMENT 3, 34.17,OTHER, 7.28, 88.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21816,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 30.61,,CLAIM ADJUSTMENT 3, 180.72,OTHER, 30.61, 348.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21817,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.66,,CLAIM ADJUSTMENT 3, 302.95,OTHER, 11.66, 602.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21818,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 36.67,,CLAIM ADJUSTMENT 3, 81.90,OTHER, 36.67, 146.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21819,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21820,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21821,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21822,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21823,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 30.58,,CLAIM ADJUSTMENT 3, 86.80,OTHER, 30.58, 159.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21824,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 30.58,,CLAIM ADJUSTMENT 3, 86.80,OTHER, 30.58, 159.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21825,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 23.12,,CLAIM ADJUSTMENT 3, 107.35,OTHER, 23.12, 204.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21826,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 23.12,,CLAIM ADJUSTMENT 3, 107.35,OTHER, 23.12, 204.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21827,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.89,,CLAIM ADJUSTMENT 3, 53.27,OTHER, 9.89, 102.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21828,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.89,,CLAIM ADJUSTMENT 3, 53.27,OTHER, 9.89, 102.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21829,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.98,,CLAIM ADJUSTMENT 3, 75.95,OTHER, 12.98, 146.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21830,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.98,,CLAIM ADJUSTMENT 3, 75.95,OTHER, 12.98, 146.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21831,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.98,,CLAIM ADJUSTMENT 3, 75.95,OTHER, 12.98, 146.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21832,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 21.29,,CLAIM ADJUSTMENT 3, 51.95,OTHER, 21.29, 94.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21833,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.19,,CLAIM ADJUSTMENT 3, 73.53,OTHER, 24.19, 136.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21834,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 73.24,,CLAIM ADJUSTMENT 3, 154.17,OTHER, 73.24, 274.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21835,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 73.24,,CLAIM ADJUSTMENT 3, 154.17,OTHER, 73.24, 274.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21836,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.42,,CLAIM ADJUSTMENT 3, 49.79,OTHER, 20.42, 90.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21837,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 38.32,OTHER, 7.46, 73.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21838,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.63,,CLAIM ADJUSTMENT 3, 35.99,OTHER, 7.63, 68.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21839,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.37,,CLAIM ADJUSTMENT 3, 58.51,OTHER, 18.37, 108.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21840,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 8.27,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 8.27, 74.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21841,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.42,,CLAIM ADJUSTMENT 3, 79.41,OTHER, 20.42, 149.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21842,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.42,,CLAIM ADJUSTMENT 3, 79.41,OTHER, 20.42, 149.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21843,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 78.90,OTHER, 24.40, 146.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21844,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 78.90,OTHER, 24.40, 146.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21845,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 22.69,,CLAIM ADJUSTMENT 3, 126.89,OTHER, 22.69, 243.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21846,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.95,,CLAIM ADJUSTMENT 3, 82.99,OTHER, 17.95, 157.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21847,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.95,,CLAIM ADJUSTMENT 3, 82.99,OTHER, 17.95, 157.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21848,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.69,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 5.69, 75.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21849,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.69,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 5.69, 75.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21850,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.69,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 5.69, 75.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21851,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 8.00,,CLAIM ADJUSTMENT 3, 22.60,OTHER, 8.00, 41.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21852,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 8.00,,CLAIM ADJUSTMENT 3, 22.60,OTHER, 8.00, 41.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21853,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.50,,CLAIM ADJUSTMENT 3, 31.87,OTHER, 6.50, 60.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21854,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.32,,CLAIM ADJUSTMENT 3, 39.10,OTHER, 7.32, 74.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21855,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.72,,CLAIM ADJUSTMENT 3, 76.33,OTHER, 16.72, 145.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21856,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.75,,CLAIM ADJUSTMENT 3, 103.71,OTHER, 19.75, 198.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21857,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.40,,CLAIM ADJUSTMENT 3, 56.68,OTHER, 16.40, 105.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21858,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.40,,CLAIM ADJUSTMENT 3, 56.68,OTHER, 16.40, 105.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21859,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.40,,CLAIM ADJUSTMENT 3, 56.68,OTHER, 16.40, 105.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21860,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 29.96, 157.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21861,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 21.67,,CLAIM ADJUSTMENT 3, 97.04,OTHER, 21.67, 184.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21862,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.94,,CLAIM ADJUSTMENT 3, 42.88,OTHER, 6.94, 82.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21863,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.47,,CLAIM ADJUSTMENT 3, 43.80,OTHER, 5.47, 85.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21864,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 17.85,OTHER, 3.41, 34.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21865,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 17.85,OTHER, 3.41, 34.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21866,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 21.46,OTHER, 3.41, 41.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21867,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 21.46,OTHER, 3.41, 41.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21868,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 22.31,OTHER, .01, 84.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21869,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.18,,CLAIM ADJUSTMENT 3, 22.31,OTHER, .01, 84.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21870,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 44.71,OTHER, 9.31, 85.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21871,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.75,,CLAIM ADJUSTMENT 3, 37.65,OTHER, 5.75, 72.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21872,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.75,,CLAIM ADJUSTMENT 3, 37.65,OTHER, 5.75, 72.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21873,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 3.66,,CLAIM ADJUSTMENT 3, 19.92,OTHER, 3.66, 38.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21874,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.46,,CLAIM ADJUSTMENT 3, 32.63,OTHER, 6.46, 62.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21875,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 25.78,,CLAIM ADJUSTMENT 3, 96.77,OTHER, 25.78, 181.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21876,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 33.04,,CLAIM ADJUSTMENT 3, 129.31,OTHER, 33.04, 243.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21877,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.06,,CLAIM ADJUSTMENT 3, 130.54,OTHER, 17.06, 253.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21878,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.93,,CLAIM ADJUSTMENT 3, 98.34,OTHER, 19.93, 187.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21879,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 22.06,,CLAIM ADJUSTMENT 3, 89.00,OTHER, 22.06, 168.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21880,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 14.66,,CLAIM ADJUSTMENT 3, 98.22,OTHER, 14.66, 190.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21881,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.99,,CLAIM ADJUSTMENT 3, 54.63,OTHER, 13.99, 102.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21882,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 27.00,,CLAIM ADJUSTMENT 3, 70.40,OTHER, 27.00, 128.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21883,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 29.86,OTHER, 6.18, 57.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21884,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 29.86,OTHER, 6.18, 57.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21885,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 29.86,OTHER, 6.18, 57.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21886,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21887,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21888,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21889,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21890,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 41.60,OTHER, 6.14, 80.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21891,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 3.89,,CLAIM ADJUSTMENT 3, 26.32,OTHER, 3.89, 50.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21892,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.93,,CLAIM ADJUSTMENT 3, 36.35,OTHER, 7.93, 69.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21893,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 8.65,,CLAIM ADJUSTMENT 3, 61.85,OTHER, 8.65, 166.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21894,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 8.65,,CLAIM ADJUSTMENT 3, 61.85,OTHER, 8.65, 166.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21895,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.26,,CLAIM ADJUSTMENT 3, 76.67,OTHER, 11.26, 148.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21896,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21897,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21898,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21899,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21900,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21901,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21902,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21903,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21904,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21905,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21906,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21907,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21908,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21909,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21910,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21911,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21912,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21913,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21914,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21915,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21916,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21917,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21918,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21919,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21920,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21921,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21922,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21923,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21924,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21925,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21926,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21927,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21928,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21929,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21930,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21931,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21932,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21933,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21934,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21935,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21936,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21937,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21938,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21939,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21940,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21941,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21942,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21943,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21944,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21945,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21946,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21947,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21948,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21949,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21950,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21951,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21952,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21953,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21954,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21955,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21956,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21957,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21958,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 26.45,,CLAIM ADJUSTMENT 3, 189.29,OTHER, 26.45, 367.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21959,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 14.46,,CLAIM ADJUSTMENT 3, 115.17,OTHER, 14.46, 224.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21960,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.41,,CLAIM ADJUSTMENT 3, 91.70,OTHER, 17.41, 220.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21961,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.41,,CLAIM ADJUSTMENT 3, 91.70,OTHER, 17.41, 220.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21962,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.07,,CLAIM ADJUSTMENT 3, 48.91,OTHER, 16.07, 90.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21963,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 10.51,,CLAIM ADJUSTMENT 3, 45.23,OTHER, 10.51, 85.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21964,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 17.08,OTHER, 7.46, 30.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21965,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 17.08,OTHER, 7.46, 30.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21966,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.65,,CLAIM ADJUSTMENT 3, 59.25,OTHER, 18.65, 110.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21967,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 36.65,,CLAIM ADJUSTMENT 3, 93.98,OTHER, 36.65, 171.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21968,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 36.65,,CLAIM ADJUSTMENT 3, 137.37,OTHER, 36.65, 258.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21969,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 23.14,,CLAIM ADJUSTMENT 3, 78.46,OTHER, 23.14, 146.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21970,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.28,,CLAIM ADJUSTMENT 3, 67.64,OTHER, 17.28, 127.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21971,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.28,,CLAIM ADJUSTMENT 3, 67.64,OTHER, 17.28, 127.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21972,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 29.26,,CLAIM ADJUSTMENT 3, 77.69,OTHER, 29.26, 141.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21973,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.65,,CLAIM ADJUSTMENT 3, 63.19,OTHER, 18.65, 117.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21974,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.79,,CLAIM ADJUSTMENT 3, 65.88,OTHER, 19.79, 127.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21975,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.79,,CLAIM ADJUSTMENT 3, 65.88,OTHER, 19.79, 127.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21976,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21977,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21978,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21979,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21980,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21981,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21982,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 68.02,OTHER, 17.35, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21983,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 68.02,OTHER, 17.35, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21984,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 68.02,OTHER, 17.35, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21985,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 120.82,OTHER, 17.35, 238.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21986,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 120.82,OTHER, 17.35, 238.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21987,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 14.46,,CLAIM ADJUSTMENT 3, 15.65,OTHER, 10.75, 24.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21988,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 80.94,OTHER, 29.96, 150.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21989,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 80.94,OTHER, 29.96, 150.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21990,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 85.12,OTHER, 29.96, 156.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21991,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 103.45,OTHER, 29.96, 193.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21992,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.97,,CLAIM ADJUSTMENT 3, 125.05,OTHER, 24.97, 345.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21993,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.97,,CLAIM ADJUSTMENT 3, 125.05,OTHER, 24.97, 345.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21994,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 50.54,OTHER, 7.46, 97.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21995,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 32.17,,CLAIM ADJUSTMENT 3, 88.87,OTHER, 32.17, 162.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21996,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 30.83,,CLAIM ADJUSTMENT 3, 66.43,OTHER, 30.83, 118.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21997,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 21.72,,CLAIM ADJUSTMENT 3, 57.43,OTHER, 21.72, 104.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21998,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 33.95,,CLAIM ADJUSTMENT 3, 265.06,OTHER, 33.95, 515.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 21999,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 80.97,OTHER, 38.57, 144.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22000,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 80.97,OTHER, 38.57, 144.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22001,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 54.34,,CLAIM ADJUSTMENT 3, 111.82,OTHER, 54.34, 198.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22002,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 67.64,,CLAIM ADJUSTMENT 3, 176.22,OTHER, 67.64, 321.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22003,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 88.05,OTHER, 38.57, 158.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22004,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 88.05,OTHER, 38.57, 158.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22005,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.84,,CLAIM ADJUSTMENT 3, 68.73,OTHER, 13.84, 131.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22006,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.95,,CLAIM ADJUSTMENT 3, 96.09,OTHER, 20.95, 205.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22007,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.95,,CLAIM ADJUSTMENT 3, 96.09,OTHER, 20.95, 205.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22008,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.60,,CLAIM ADJUSTMENT 3, 70.10,OTHER, 19.60, 131.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22009,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 8.16,,CLAIM ADJUSTMENT 3, 46.86,OTHER, 8.16, 90.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22010,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 8.16,,CLAIM ADJUSTMENT 3, 46.86,OTHER, 8.16, 90.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22011,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 89.24,,CLAIM ADJUSTMENT 3, 191.67,OTHER, 89.24, 342.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22012,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.33,,CLAIM ADJUSTMENT 3, 12.31,OTHER, 8.04, 18.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22013,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.34,,CLAIM ADJUSTMENT 3, 18.56,OTHER, 6.34, 34.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22014,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 21.67,,CLAIM ADJUSTMENT 3, 36.21,OTHER, 21.67, 62.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22015,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 14.66,,CLAIM ADJUSTMENT 3, 55.25,OTHER, 14.66, 103.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22016,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.58,,CLAIM ADJUSTMENT 3, 40.13,OTHER, 18.58, 71.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22017,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.00,,CLAIM ADJUSTMENT 3, 66.54,OTHER, 19.00, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22018,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.53,,CLAIM ADJUSTMENT 3, 88.38,OTHER, 24.53, 165.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22019,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.53,,CLAIM ADJUSTMENT 3, 88.38,OTHER, 24.53, 165.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22020,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.53,,CLAIM ADJUSTMENT 3, 88.38,OTHER, 24.53, 165.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22021,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.29,,CLAIM ADJUSTMENT 3, 26.75,OTHER, 17.29, 45.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22022,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.51,,CLAIM ADJUSTMENT 3, 91.08,OTHER, 16.51, 254.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22023,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.51,,CLAIM ADJUSTMENT 3, 91.08,OTHER, 16.51, 254.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22024,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 50.83,OTHER, 20.72, 92.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22025,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 59.00,OTHER, 24.26, 106.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22026,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 22.02,,CLAIM ADJUSTMENT 3, 64.46,OTHER, 22.02, 118.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22027,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 26.12,,CLAIM ADJUSTMENT 3, 59.50,OTHER, 26.12, 106.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22028,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 26.12,,CLAIM ADJUSTMENT 3, 59.50,OTHER, 26.12, 106.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22029,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 71.41,OTHER, 24.26, 179.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22030,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 71.41,OTHER, 24.26, 179.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22031,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 71.41,OTHER, 24.26, 179.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22032,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 27.86,,CLAIM ADJUSTMENT 3, 66.70,OTHER, 27.86, 120.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22033,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 27.86,,CLAIM ADJUSTMENT 3, 66.70,OTHER, 27.86, 120.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22034,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 43.51,OTHER, 20.72, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22035,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.00,,CLAIM ADJUSTMENT 3, 47.68,OTHER, 19.00, 86.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22036,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 27.86,,CLAIM ADJUSTMENT 3, 58.39,OTHER, 27.86, 103.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22037,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.86,,CLAIM ADJUSTMENT 3, 77.47,OTHER, 19.86, 145.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22038,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.74,,CLAIM ADJUSTMENT 3, 62.50,OTHER, 19.74, 116.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22039,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 46.75,OTHER, 17.35, 85.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22040,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.94,,CLAIM ADJUSTMENT 3, 41.14,OTHER, 16.94, 74.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22041,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 67.08,OTHER, 15.47, 127.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22042,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.84,,CLAIM ADJUSTMENT 3, 50.52,OTHER, 17.84, 92.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22043,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.21,,CLAIM ADJUSTMENT 3, 28.18,OTHER, 16.21, 48.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22044,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.79,,CLAIM ADJUSTMENT 3, 52.54,OTHER, 18.79, 96.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22045,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.79,,CLAIM ADJUSTMENT 3, 52.54,OTHER, 18.79, 96.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22046,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.07,,CLAIM ADJUSTMENT 3, 41.16,OTHER, 19.07, 73.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22047,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 46.11,OTHER, 20.72, 82.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22048,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 46.11,OTHER, 20.72, 82.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22049,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 46.11,OTHER, 20.72, 82.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22050,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 48.00,OTHER, 18.55, 88.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22051,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 48.00,OTHER, 18.55, 88.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22052,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 48.00,OTHER, 18.55, 88.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22053,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.07,,CLAIM ADJUSTMENT 3, 49.38,OTHER, 19.07, 89.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22054,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 80.11,OTHER, 18.55, 151.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22055,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 80.11,OTHER, 18.55, 151.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22056,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 361.76,OTHER, 18.55, 717.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22057,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 20.54,,CLAIM ADJUSTMENT 3, 161.64,OTHER, 20.54, 314.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22058,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 92.44,,CLAIM ADJUSTMENT 3, 158.63,OTHER, 92.44, 274.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22059,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 92.44,,CLAIM ADJUSTMENT 3, 158.63,OTHER, 92.44, 274.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22060,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 14.06,,CLAIM ADJUSTMENT 3, 78.01,OTHER, 14.06, 149.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22061,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 14.06,,CLAIM ADJUSTMENT 3, 78.01,OTHER, 14.06, 149.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22062,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 14.06,,CLAIM ADJUSTMENT 3, 78.01,OTHER, 14.06, 149.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22063,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 152.44,OTHER, 102.77, 234.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22064,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 251.30,,CLAIM ADJUSTMENT 3, 270.23,OTHER, 185.27, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22065,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 251.30,,CLAIM ADJUSTMENT 3, 270.23,OTHER, 185.27, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22066,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 251.30,,CLAIM ADJUSTMENT 3, 270.23,OTHER, 185.27, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22067,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22068,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22069,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22070,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22071,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22072,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 146.86,OTHER, 7.46, 291.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22073,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 54.74,OTHER, 4.31, 107.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22074,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 54.74,OTHER, 4.31, 107.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22075,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 54.74,OTHER, 4.31, 107.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22076,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 44.77,OTHER, 4.31, 89.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22077,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 44.77,OTHER, 4.31, 89.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22078,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 44.77,OTHER, 4.31, 89.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22079,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.52,,CLAIM ADJUSTMENT 3, 205.30,OTHER, 5.52, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22080,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.52,,CLAIM ADJUSTMENT 3, 205.30,OTHER, 5.52, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22081,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.52,,CLAIM ADJUSTMENT 3, 205.30,OTHER, 5.52, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22082,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.16,,CLAIM ADJUSTMENT 3, 70.78,OTHER, 11.16, 136.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22083,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.16,,CLAIM ADJUSTMENT 3, 70.78,OTHER, 11.16, 136.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22084,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22085,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22086,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22087,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22088,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22089,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22090,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 35.20,,CLAIM ADJUSTMENT 3, 76.50,OTHER, 35.20, 136.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22091,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 91.25,,CLAIM ADJUSTMENT 3, 149.18,OTHER, 91.25, 255.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22092,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 14.86,,CLAIM ADJUSTMENT 3, 81.41,OTHER, 14.86, 156.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22093,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 14.86,,CLAIM ADJUSTMENT 3, 81.41,OTHER, 14.86, 156.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22094,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.60,,CLAIM ADJUSTMENT 3, 30.76,OTHER, 13.60, 55.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22095,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.41,,CLAIM ADJUSTMENT 3, 72.64,OTHER, 12.41, 139.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22096,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.41,,CLAIM ADJUSTMENT 3, 72.64,OTHER, 12.41, 139.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22097,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.63,,CLAIM ADJUSTMENT 3, 78.26,OTHER, 13.63, 150.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22098,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 13.63,,CLAIM ADJUSTMENT 3, 78.26,OTHER, 13.63, 150.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22099,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 78.99,OTHER, 11.64, 152.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22100,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 46.77,OTHER, 11.64, 88.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22101,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 46.77,OTHER, 11.64, 88.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22102,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 46.77,OTHER, 11.64, 88.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22103,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 9.55,,CLAIM ADJUSTMENT 3, 40.96,OTHER, 9.55, 77.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22104,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.62,,CLAIM ADJUSTMENT 3, 44.68,OTHER, 11.62, 84.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22105,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.62,,CLAIM ADJUSTMENT 3, 44.68,OTHER, 11.62, 84.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22106,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.62,,CLAIM ADJUSTMENT 3, 44.68,OTHER, 11.62, 84.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22107,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.65,,CLAIM ADJUSTMENT 3, 82.26,OTHER, 11.65, 159.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22108,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 11.65,,CLAIM ADJUSTMENT 3, 82.26,OTHER, 11.65, 159.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22109,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.11,,CLAIM ADJUSTMENT 3, 74.74,OTHER, 12.11, 144.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22110,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 15.55,,CLAIM ADJUSTMENT 3, 91.00,OTHER, 15.55, 175.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22111,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.82,,CLAIM ADJUSTMENT 3, 68.31,OTHER, 12.82, 130.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22112,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 17.74,OTHER, 6.84, 32.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22113,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 10.78,,CLAIM ADJUSTMENT 3, 22.99,OTHER, 10.78, 40.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22114,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 29.95,OTHER, 6.84, 56.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22115,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 12.46,,CLAIM ADJUSTMENT 3, 42.41,OTHER, 12.46, 79.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22116,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22117,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22118,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22119,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22120,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22121,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 38.14,OTHER, 7.76, 72.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22122,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 38.14,OTHER, 7.76, 72.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22123,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 8.38,,CLAIM ADJUSTMENT 3, 28.29,OTHER, 8.38, 52.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22124,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 28.16,,CLAIM ADJUSTMENT 3, 68.72,OTHER, 28.16, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22125,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.26,,CLAIM ADJUSTMENT 3, 299.39,OTHER, 17.26, 592.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22126,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 14.88,,CLAIM ADJUSTMENT 3, 40.67,OTHER, 14.88, 74.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22127,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 43.08,OTHER, 16.61, 78.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22128,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 121.25,OTHER, 19.08, 234.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22129,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 28.87,,CLAIM ADJUSTMENT 3, 68.89,OTHER, 28.87, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22130,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 106.28,OTHER, 50.53, 189.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22131,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 106.28,OTHER, 50.53, 189.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22132,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 53.66,,CLAIM ADJUSTMENT 3, 107.02,OTHER, 53.66, 189.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22133,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 53.66,,CLAIM ADJUSTMENT 3, 107.02,OTHER, 53.66, 189.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22134,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 53.66,,CLAIM ADJUSTMENT 3, 107.02,OTHER, 53.66, 189.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22135,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 198.86,OTHER, 61.69, 369.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22136,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 198.86,OTHER, 61.69, 369.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22137,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22138,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 221.47,OTHER, 61.69, 415.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22139,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 76.43,OTHER, 50.53, 129.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22140,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 122.54,,CLAIM ADJUSTMENT 3, 265.03,OTHER, 122.54, 473.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22141,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 106.28,OTHER, 50.53, 189.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22142,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22143,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22144,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 600.16,,CLAIM ADJUSTMENT 3, 445.68,OTHER, 266.63, 607.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22145,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22146,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22147,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22148,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 193.99,OTHER, 50.53, 365.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22149,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 193.99,OTHER, 50.53, 365.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22150,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22151,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 173.66,OTHER, 50.53, 324.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22152,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 28.87,,CLAIM ADJUSTMENT 3, 68.89,OTHER, 28.87, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22153,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 204.22,OTHER, 50.53, 599.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22154,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 204.22,OTHER, 50.53, 599.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22155,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 146.52,OTHER, 61.69, 264.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22156,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 146.52,OTHER, 61.69, 264.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22157,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 23.83,,CLAIM ADJUSTMENT 3, 62.25,OTHER, 23.83, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22158,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 23.83,,CLAIM ADJUSTMENT 3, 62.25,OTHER, 23.83, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22159,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.86,,CLAIM ADJUSTMENT 3, 43.07,OTHER, 18.86, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22160,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.86,,CLAIM ADJUSTMENT 3, 43.07,OTHER, 18.86, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22161,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 23.81,,CLAIM ADJUSTMENT 3, 44.25,OTHER, 23.81, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22162,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 23.81,,CLAIM ADJUSTMENT 3, 17.88,OTHER, 10.75, 24.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22163,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 23.14,,CLAIM ADJUSTMENT 3, 100.14,OTHER, 23.14, 189.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22164,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 370.73,,CLAIM ADJUSTMENT 3, 800.72,OTHER, 370.73, 1429.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22165,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 370.73,,CLAIM ADJUSTMENT 3, 800.72,OTHER, 370.73, 1429.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22166,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 38.32,,CLAIM ADJUSTMENT 3, 59.91,OTHER, 38.32, 101.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22167,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 38.32,,CLAIM ADJUSTMENT 3, 59.91,OTHER, 38.32, 101.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22168,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 97.97,,CLAIM ADJUSTMENT 3, 294.34,OTHER, 97.97, 543.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22169,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22170,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22171,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.79,,CLAIM ADJUSTMENT 3, 16.75,OTHER, 6.79, 30.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22172,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 6.79,,CLAIM ADJUSTMENT 3, 16.75,OTHER, 6.79, 30.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22173,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 8.06,,CLAIM ADJUSTMENT 3, 56.81,OTHER, 8.06, 110.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22174,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 10.56,,CLAIM ADJUSTMENT 3, 39.98,OTHER, 10.56, 75.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22175,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 41.73,OTHER, 17.35, 75.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22176,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22177,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 63.90,OTHER, 37.34, 110.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22178,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 63.90,OTHER, 37.34, 110.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22179,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 23.30,OTHER, 12.69, 37.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22180,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 37.95,OTHER, 25.59, 58.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22181,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 23.42,OTHER, 12.79, 37.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22182,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22183,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22184,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 315.54,,CLAIM ADJUSTMENT 3, 149.84,OTHER, 65.79, 315.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22185,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 315.54,,CLAIM ADJUSTMENT 3, 149.84,OTHER, 65.79, 315.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22186,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22187,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 71.34,,CLAIM ADJUSTMENT 3, 41.40,OTHER, 21.50, 71.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22188,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 71.34,,CLAIM ADJUSTMENT 3, 41.40,OTHER, 21.50, 71.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22189,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 280.30,,CLAIM ADJUSTMENT 3, 356.50,OTHER, 255.16, 581.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22190,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 345.38,,CLAIM ADJUSTMENT 3, 687.64,OTHER, 345.38, 1214.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22191,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22192,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22193,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22194,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 77.65,,CLAIM ADJUSTMENT 3, 60.00,OTHER, 36.55, 83.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22195,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 48.79,,CLAIM ADJUSTMENT 3, 36.74,OTHER, 22.12, 50.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22196,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 48.79,,CLAIM ADJUSTMENT 3, 36.74,OTHER, 22.12, 50.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22197,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22198,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22199,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22200,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22201,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22202,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22203,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22204,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22205,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22206,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22207,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22208,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 143.83,,CLAIM ADJUSTMENT 3, 111.30,OTHER, 67.85, 154.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22209,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 143.83,,CLAIM ADJUSTMENT 3, 111.30,OTHER, 67.85, 154.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22210,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22211,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22212,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 89.44,,CLAIM ADJUSTMENT 3, 104.75,OTHER, 73.49, 167.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22213,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 89.44,,CLAIM ADJUSTMENT 3, 104.75,OTHER, 73.49, 167.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22214,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 33.16,,CLAIM ADJUSTMENT 3, 12.78,OTHER, 4.30, 33.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22215,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 5.09,,CLAIM ADJUSTMENT 3, 17.36,OTHER, 5.09, 32.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22216,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 184.48,OTHER, 130.68, 297.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22217,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 202.35,OTHER, 146.42, 333.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22218,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 113.95,,CLAIM ADJUSTMENT 3, 99.37,OTHER, 63.61, 144.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22219,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 59.56,,CLAIM ADJUSTMENT 3, 88.44,OTHER, 59.56, 149.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22220,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 131.72,OTHER, 84.22, 191.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22221,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 96.67,,CLAIM ADJUSTMENT 3, 117.05,OTHER, 82.81, 188.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22222,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 179.75,OTHER, 126.51, 288.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22223,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 143.72,,CLAIM ADJUSTMENT 3, 158.52,OTHER, 109.46, 249.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22224,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 186.21,OTHER, 132.20, 301.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22225,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 50.93,,CLAIM ADJUSTMENT 3, 83.96,OTHER, 50.93, 144.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22226,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 216.78,,CLAIM ADJUSTMENT 3, 167.44,OTHER, 102.00, 232.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22227,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 216.78,,CLAIM ADJUSTMENT 3, 172.28,OTHER, 106.26, 242.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22228,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 87.35,,CLAIM ADJUSTMENT 3, 49.86,OTHER, 25.59, 87.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22229,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 85.51,,CLAIM ADJUSTMENT 3, 141.43,OTHER, 85.51, 242.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22230,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 69.71,OTHER, 45.42, 103.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22231,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 177.65,OTHER, 120.47, 274.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22232,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 189.46,OTHER, 130.87, 298.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22233,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 279.93,OTHER, 171.54, 479.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22234,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 265.00,OTHER, 171.54, 449.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22235,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 113.59,,CLAIM ADJUSTMENT 3, 149.90,OTHER, 108.18, 246.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22236,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 46.09,,CLAIM ADJUSTMENT 3, 167.02,OTHER, 46.09, 313.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22237,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 46.09,,CLAIM ADJUSTMENT 3, 76.10,OTHER, 46.09, 130.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22238,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 46.09,,CLAIM ADJUSTMENT 3, 147.35,OTHER, 46.09, 273.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22239,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 227.22,OTHER, 124.32, 396.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22240,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 295.49,OTHER, 124.32, 533.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22241,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 114.40,OTHER, 74.67, 170.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22242,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 155.48,OTHER, 110.85, 252.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22243,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22244,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22245,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22246,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 114.13,,CLAIM ADJUSTMENT 3, 36.72,OTHER, 8.41, 114.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22247,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 114.13,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 114.13, 360.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22248,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 114.13,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 114.13, 360.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22249,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 346.21,,CLAIM ADJUSTMENT 3, 526.62,OTHER, 346.21, 891.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22250,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 346.21,,CLAIM ADJUSTMENT 3, 290.83,OTHER, 143.52, 346.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22251,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22252,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 49.24,,CLAIM ADJUSTMENT 3, 162.12,OTHER, 49.24, 301.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22253,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 80.99,,CLAIM ADJUSTMENT 3, 140.39,OTHER, 80.99, 243.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22254,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 80.99,,CLAIM ADJUSTMENT 3, 140.39,OTHER, 80.99, 243.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22255,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 51.13,,CLAIM ADJUSTMENT 3, 166.97,OTHER, 51.13, 310.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22256,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 51.13,,CLAIM ADJUSTMENT 3, 54.96,OTHER, 37.67, 85.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22257,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 51.13,,CLAIM ADJUSTMENT 3, 86.43,OTHER, 51.13, 149.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22258,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 656.16,,CLAIM ADJUSTMENT 3, 950.56,OTHER, 656.16, 1594.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22259,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 656.16,,CLAIM ADJUSTMENT 3, 375.80,OTHER, 121.44, 656.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22260,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 545.72,OTHER, 384.68, 911.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22261,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 545.72,OTHER, 384.68, 911.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22262,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 278.85,OTHER, 121.44, 384.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22263,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 278.85,OTHER, 121.44, 384.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22264,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 591.97,OTHER, 225.62, 1080.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22265,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22266,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 96.59,,CLAIM ADJUSTMENT 3, 250.40,OTHER, 96.59, 456.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22267,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 96.59,,CLAIM ADJUSTMENT 3, 250.40,OTHER, 96.59, 456.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22268,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 157.67,,CLAIM ADJUSTMENT 3, 197.77,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22269,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 563.65,OTHER, 225.62, 1023.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22270,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22271,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 113.30,OTHER, 70.09, 159.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22272,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 113.30,OTHER, 70.09, 159.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22273,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22274,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22275,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 297.88,OTHER, 215.00, 490.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22276,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22277,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 262.11,OTHER, 141.55, 458.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22278,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 262.11,OTHER, 141.55, 458.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22279,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22280,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22281,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 673.61,OTHER, 225.62, 1244.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22282,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 673.61,OTHER, 225.62, 1244.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22283,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 383.08,OTHER, 225.62, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22284,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 673.61,OTHER, 225.62, 1244.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22285,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22286,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22287,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22288,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22289,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22290,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22291,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22292,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22293,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22294,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22295,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22296,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22297,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 655.39,OTHER, 225.62, 1207.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22298,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22299,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 284.89,,CLAIM ADJUSTMENT 3, 1042.14,OTHER, 284.89, 2539.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22300,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 284.89,,CLAIM ADJUSTMENT 3, 1042.14,OTHER, 284.89, 2539.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22301,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 184.77,OTHER, 39.56, 427.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22302,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 184.77,OTHER, 39.56, 427.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22303,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 138.71,,CLAIM ADJUSTMENT 3, 547.41,OTHER, 138.71, 1032.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22304,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 152.82,,CLAIM ADJUSTMENT 3, 154.36,OTHER, 103.88, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22305,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 152.82,,CLAIM ADJUSTMENT 3, 154.36,OTHER, 103.88, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22306,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 199.86,OTHER, 125.79, 286.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22307,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 199.86,OTHER, 125.79, 286.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22308,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 407.38,OTHER, 140.42, 864.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22309,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 407.38,OTHER, 140.42, 864.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22310,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 407.38,OTHER, 140.42, 864.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22311,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 332.46,OTHER, 140.42, 600.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22312,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 239.03,OTHER, 160.29, 365.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22313,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 239.03,OTHER, 160.29, 365.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22314,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 174.98,OTHER, 103.88, 239.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22315,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 136.10,OTHER, 76.16, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22316,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 140.33,OTHER, 74.39, 234.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22317,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 87.35,,CLAIM ADJUSTMENT 3, 228.33,OTHER, 87.35, 416.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22318,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22319,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22320,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 94.34,,CLAIM ADJUSTMENT 3, 182.46,OTHER, 94.34, 321.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22321,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 94.34,,CLAIM ADJUSTMENT 3, 182.46,OTHER, 94.34, 321.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22322,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 125.89,OTHER, 61.67, 234.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22323,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 125.89,OTHER, 61.67, 234.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22324,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 235.80,,CLAIM ADJUSTMENT 3, 415.63,OTHER, 235.80, 721.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22325,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 1853.96,OTHER, 1121.15, 3185.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22326,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 1853.96,OTHER, 1121.15, 3185.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22327,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 2171.37,OTHER, 1121.15, 3822.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22328,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 2171.37,OTHER, 1121.15, 3822.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22329,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 2171.37,OTHER, 1121.15, 3822.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22330,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 85.61,,CLAIM ADJUSTMENT 3, 152.82,OTHER, 85.61, 265.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22331,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 89.47,,CLAIM ADJUSTMENT 3, 165.98,OTHER, 89.47, 290.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22332,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 110.12,,CLAIM ADJUSTMENT 3, 260.74,OTHER, 110.12, 470.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22333,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 110.12,,CLAIM ADJUSTMENT 3, 260.74,OTHER, 110.12, 470.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22334,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 96.89,OTHER, 37.34, 176.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22335,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 96.89,OTHER, 37.34, 176.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22336,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 184.46,,CLAIM ADJUSTMENT 3, 323.07,OTHER, 184.46, 560.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22337,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 184.46,,CLAIM ADJUSTMENT 3, 323.07,OTHER, 184.46, 560.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22338,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 184.46,,CLAIM ADJUSTMENT 3, 323.07,OTHER, 184.46, 560.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22339,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 89.33,OTHER, 37.34, 161.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22340,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 89.33,OTHER, 37.34, 161.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22341,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 108.89,OTHER, 54.48, 192.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22342,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 108.89,OTHER, 54.48, 192.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22343,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22344,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22345,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 84.04,OTHER, 37.34, 150.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22346,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 84.04,OTHER, 37.34, 150.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22347,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 37.95,OTHER, 25.59, 58.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22348,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 37.95,OTHER, 25.59, 58.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22349,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 159.88,OTHER, 54.48, 294.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22350,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 159.88,OTHER, 54.48, 294.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22351,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 96.44,OTHER, 54.48, 167.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22352,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 96.44,OTHER, 54.48, 167.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22353,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22354,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22355,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 21.01,,CLAIM ADJUSTMENT 3, 47.95,OTHER, 21.01, 86.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22356,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 21.01,,CLAIM ADJUSTMENT 3, 47.95,OTHER, 21.01, 86.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22357,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 34.39,,CLAIM ADJUSTMENT 3, 55.33,OTHER, 34.39, 94.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22358,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 34.39,,CLAIM ADJUSTMENT 3, 55.33,OTHER, 34.39, 94.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22359,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 29.74,,CLAIM ADJUSTMENT 3, 58.74,OTHER, 29.74, 103.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22360,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 29.74,,CLAIM ADJUSTMENT 3, 58.74,OTHER, 29.74, 103.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22361,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 29.74,,CLAIM ADJUSTMENT 3, 58.74,OTHER, 29.74, 103.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22362,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 28.82,,CLAIM ADJUSTMENT 3, 142.33,OTHER, 28.82, 411.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22363,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 28.82,,CLAIM ADJUSTMENT 3, 142.33,OTHER, 28.82, 411.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22364,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 28.82,,CLAIM ADJUSTMENT 3, 72.71,OTHER, 28.82, 132.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22365,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 74.33,OTHER, 52.80, 120.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22366,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 74.33,OTHER, 52.80, 120.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22367,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 74.35,OTHER, 52.84, 120.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22368,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 69.01,,CLAIM ADJUSTMENT 3, 80.43,OTHER, 56.36, 128.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22369,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 69.01,,CLAIM ADJUSTMENT 3, 80.43,OTHER, 56.36, 128.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22370,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 69.01,,CLAIM ADJUSTMENT 3, 80.43,OTHER, 56.36, 128.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22371,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 60.80,OTHER, 40.91, 93.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22372,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 60.80,OTHER, 40.91, 93.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22373,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 61.55,,CLAIM ADJUSTMENT 3, 47.68,OTHER, 29.08, 66.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22374,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 46.96,,CLAIM ADJUSTMENT 3, 98.59,OTHER, 46.96, 175.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22375,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 46.96,,CLAIM ADJUSTMENT 3, 98.59,OTHER, 46.96, 175.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22376,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 46.96,,CLAIM ADJUSTMENT 3, 98.59,OTHER, 46.96, 175.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22377,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 44.87,,CLAIM ADJUSTMENT 3, 115.67,OTHER, 44.87, 210.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22378,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 44.87,,CLAIM ADJUSTMENT 3, 115.67,OTHER, 44.87, 210.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22379,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 44.87,,CLAIM ADJUSTMENT 3, 115.67,OTHER, 44.87, 210.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22380,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 55.58,,CLAIM ADJUSTMENT 3, 73.14,OTHER, 52.75, 120.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22381,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 55.58,,CLAIM ADJUSTMENT 3, 73.14,OTHER, 52.75, 120.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22382,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 55.58,,CLAIM ADJUSTMENT 3, 73.14,OTHER, 52.75, 120.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22383,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.13,,CLAIM ADJUSTMENT 3, 30.33,OTHER, 18.92, 43.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22384,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 206.21,,CLAIM ADJUSTMENT 3, 178.52,OTHER, 113.97, 259.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22385,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 206.21,,CLAIM ADJUSTMENT 3, 202.67,OTHER, 135.24, 308.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22386,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 206.21,,CLAIM ADJUSTMENT 3, 194.50,OTHER, 128.04, 291.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22387,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 142.50,,CLAIM ADJUSTMENT 3, 106.37,OTHER, 63.79, 145.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22388,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 208.14,,CLAIM ADJUSTMENT 3, 173.75,OTHER, 109.36, 249.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22389,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 208.14,,CLAIM ADJUSTMENT 3, 180.83,OTHER, 115.60, 263.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22390,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 208.14,,CLAIM ADJUSTMENT 3, 204.49,OTHER, 136.43, 310.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22391,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 143.15,,CLAIM ADJUSTMENT 3, 108.91,OTHER, 65.89, 150.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22392,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 41.16,,CLAIM ADJUSTMENT 3, 68.75,OTHER, 41.16, 118.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22393,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 41.16,,CLAIM ADJUSTMENT 3, 68.75,OTHER, 41.16, 118.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22394,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 41.16,,CLAIM ADJUSTMENT 3, 68.75,OTHER, 41.16, 118.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22395,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 44.69,OTHER, 31.56, 71.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22396,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 66.74,,CLAIM ADJUSTMENT 3, 78.22,OTHER, 54.89, 125.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22397,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 66.74,,CLAIM ADJUSTMENT 3, 78.22,OTHER, 54.89, 125.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22398,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 66.74,,CLAIM ADJUSTMENT 3, 59.17,OTHER, 38.11, 86.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22399,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 39.73,,CLAIM ADJUSTMENT 3, 66.10,OTHER, 39.73, 113.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22400,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 39.73,,CLAIM ADJUSTMENT 3, 66.10,OTHER, 39.73, 113.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22401,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 39.73,,CLAIM ADJUSTMENT 3, 66.10,OTHER, 39.73, 113.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22402,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 68.90,OTHER, 12.81, 151.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22403,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 96.26,,CLAIM ADJUSTMENT 3, 93.12,OTHER, 61.82, 140.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22404,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 84.59,,CLAIM ADJUSTMENT 3, 114.40,OTHER, 52.03, 259.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22405,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 84.59,,CLAIM ADJUSTMENT 3, 114.40,OTHER, 52.03, 259.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22406,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 105.23,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 53.32, 121.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22407,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 105.23,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 53.32, 121.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22408,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 105.23,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 53.32, 121.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22409,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22410,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22411,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22412,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22413,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22414,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22415,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22416,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22417,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22418,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22419,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 114.64,,CLAIM ADJUSTMENT 3, 145.27,OTHER, 103.88, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22420,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22421,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22422,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22423,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22424,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22425,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22426,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22427,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22428,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22429,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22430,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22431,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22432,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22433,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22434,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22435,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22436,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22437,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22438,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22439,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 103.66,,CLAIM ADJUSTMENT 3, 111.61,OTHER, 64.03, 142.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22440,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 164.56,,CLAIM ADJUSTMENT 3, 149.82,OTHER, 78.16, 173.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22441,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 247.58,,CLAIM ADJUSTMENT 3, 220.11,OTHER, 113.05, 250.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22442,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 149.74,OTHER, 77.35, 263.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22443,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 149.74,OTHER, 77.35, 263.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22444,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 156.74,OTHER, 77.35, 245.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22445,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 156.74,OTHER, 77.35, 245.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22446,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 233.57,OTHER, 127.82, 407.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22447,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 233.57,OTHER, 127.82, 407.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22448,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 197.91,OTHER, 127.82, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22449,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 197.91,OTHER, 127.82, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22450,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 369.55,OTHER, 203.96, 644.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22451,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 369.55,OTHER, 203.96, 644.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22452,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 247.74,OTHER, 150.14, 333.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22453,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 247.74,OTHER, 150.14, 333.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22454,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 580.80,OTHER, 324.71, 1010.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22455,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 580.80,OTHER, 324.71, 1010.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22456,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 332.53,OTHER, 185.91, 412.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22457,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 332.53,OTHER, 185.91, 412.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22458,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 479.76,,CLAIM ADJUSTMENT 3, 954.02,OTHER, 479.76, 1685.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22459,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 479.76,,CLAIM ADJUSTMENT 3, 954.02,OTHER, 479.76, 1685.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22460,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 479.76,,CLAIM ADJUSTMENT 3, 429.06,OTHER, 221.24, 490.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22461,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 720.78,,CLAIM ADJUSTMENT 3, 1514.86,OTHER, 720.78, 2695.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22462,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22463,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22464,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22465,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22466,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 167.97,OTHER, 113.31, 258.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22467,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 173.37,OTHER, 118.06, 269.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22468,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 179.18,OTHER, 123.17, 280.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22469,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 197.44,OTHER, 139.26, 317.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22470,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 192.88,OTHER, 135.24, 308.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22471,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22472,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22473,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 155.10,OTHER, 101.97, 232.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22474,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 162.99,OTHER, 108.92, 248.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22475,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 174.20,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22476,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 174.20,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22477,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 174.20,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22478,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 177.10,OTHER, 121.35, 276.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22479,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22480,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22481,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22482,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22483,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22484,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22485,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 30.74,,CLAIM ADJUSTMENT 3, 33.14,OTHER, 22.74, 51.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22486,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 30.74,,CLAIM ADJUSTMENT 3, 39.28,OTHER, 28.14, 64.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22487,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22488,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22489,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22490,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22491,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 101.33,,CLAIM ADJUSTMENT 3, 148.65,OTHER, 101.33, 249.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22492,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 133.36,,CLAIM ADJUSTMENT 3, 166.04,OTHER, 118.25, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22493,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22494,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22495,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 680.93,,CLAIM ADJUSTMENT 3, 350.13,OTHER, 165.55, 680.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22496,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 680.93,,CLAIM ADJUSTMENT 3, 350.13,OTHER, 165.55, 680.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22497,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1078.14,,CLAIM ADJUSTMENT 3, 553.11,OTHER, 261.01, 1078.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22498,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1078.14,,CLAIM ADJUSTMENT 3, 553.11,OTHER, 261.01, 1078.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22499,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 567.43,,CLAIM ADJUSTMENT 3, 308.45,OTHER, 152.65, 567.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22500,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 567.43,,CLAIM ADJUSTMENT 3, 308.45,OTHER, 152.65, 567.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22501,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 907.91,,CLAIM ADJUSTMENT 3, 466.19,OTHER, 220.16, 907.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22502,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 907.91,,CLAIM ADJUSTMENT 3, 466.19,OTHER, 220.16, 907.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22503,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22504,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22505,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22506,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22507,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22508,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22509,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22510,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1648.47,OTHER, 779.04, 2936.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22511,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1648.47,OTHER, 779.04, 2936.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22512,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1777.88,OTHER, 779.04, 3195.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22513,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1777.88,OTHER, 779.04, 3195.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22514,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1244.21,OTHER, 508.57, 2254.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22515,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1244.21,OTHER, 508.57, 2254.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22516,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1244.21,OTHER, 508.57, 2254.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22517,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1097.72,OTHER, 508.57, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22518,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1097.72,OTHER, 508.57, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22519,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1162.11,OTHER, 779.04, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22520,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1162.11,OTHER, 779.04, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22521,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1.66,,CLAIM ADJUSTMENT 3, 9.74,OTHER, 1.66, 18.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22522,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 63.90,OTHER, 37.34, 110.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22523,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 11.82,OTHER, 2.58, 37.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22524,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22525,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22526,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 33.71,,CLAIM ADJUSTMENT 3, 88.75,OTHER, 33.71, 162.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22527,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 33.71,,CLAIM ADJUSTMENT 3, 58.81,OTHER, 33.71, 101.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22528,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22529,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 231.89,OTHER, 165.06, 386.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22530,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 231.89,OTHER, 165.06, 386.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22531,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 35.44,OTHER, 18.28, 61.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22532,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 44.57,OTHER, 26.32, 61.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22533,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22534,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22535,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22536,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22537,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22538,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22539,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22540,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22541,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22542,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22543,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22544,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22545,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22546,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22547,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22548,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22549,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22550,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22551,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22552,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22553,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22554,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22555,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22556,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22557,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1597.44,,CLAIM ADJUSTMENT 3, 575.18,OTHER, 171.57, 1597.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22558,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2082.47,,CLAIM ADJUSTMENT 3, 690.66,OTHER, 171.57, 2082.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22559,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1937.50,,CLAIM ADJUSTMENT 3, 656.15,OTHER, 171.57, 1937.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22560,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 1734.01,,CLAIM ADJUSTMENT 3, 607.70,OTHER, 171.57, 1734.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22561,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 2065.06,,CLAIM ADJUSTMENT 3, 735.35,OTHER, 214.57, 2065.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22562,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 18.42,,CLAIM ADJUSTMENT 3, 421.89,OTHER, 18.42, 837.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22563,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22564,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22565,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22566,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22567,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22568,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22569,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22570,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22571,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22572,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22573,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22574,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22575,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22576,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22577,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22578,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22579,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22580,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22581,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22582,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22583,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22584,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22585,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22586,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22587,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22588,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22589,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22590,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22591,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22592,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22593,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22594,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22595,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22596,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22597,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22598,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22599,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22600,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 42.53,,CLAIM ADJUSTMENT 3, 62.01,OTHER, 42.53, 104.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22601,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22602,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22603,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22604,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22605,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22606,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22607,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22608,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22609,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22610,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22611,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22612,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22613,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22614,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22615,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22616,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22617,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22618,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22619,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22620,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22621,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22622,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22623,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22624,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22625,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22626,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22627,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22628,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22629,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22630,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22631,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22632,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22633,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22634,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22635,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22636,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22637,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22638,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22639,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22640,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22641,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22642,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22643,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22644,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22645,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22646,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22647,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22648,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22649,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22650,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22651,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22652,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22653,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22654,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22655,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22656,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22657,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22658,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22659,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22660,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22661,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22662,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22663,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22664,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22665,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22666,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22667,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22668,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22669,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22670,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22671,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22672,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22673,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22674,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22675,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22676,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22677,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22678,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22679,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22680,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22681,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22682,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22683,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22684,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22685,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22686,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22687,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22688,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22689,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22690,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22691,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22692,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22693,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22694,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22695,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22696,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22697,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22698,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22699,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22700,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22701,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22702,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22703,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22704,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22705,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22706,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22707,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22708,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22709,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22710,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22711,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22712,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22713,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22714,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22715,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22716,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22717,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22718,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22719,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22720,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22721,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22722,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22723,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22724,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22725,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22726,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22727,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22728,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22729,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22730,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22731,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22732,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 22733,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,MOLINA_TURQ_MEDICAID,MOLINA TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 22734,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,MULTIPLAN,MULTIPLAN, 1035.00,,OUTPCT LIMIT, 920.20,OTHER, 507.84, 1127.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22735,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,MULTIPLAN,MULTIPLAN, 765.00,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22736,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,MULTIPLAN,MULTIPLAN, 1237.50,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22737,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22738,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22739,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22740,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22741,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22742,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22743,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22744,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22745,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22746,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22747,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22748,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22749,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22750,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22751,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22752,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,MULTIPLAN,MULTIPLAN, 438.12,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22753,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,MULTIPLAN,MULTIPLAN, 438.12,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22754,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,MULTIPLAN,MULTIPLAN, 248.63,,OUTPCT LIMIT, 168.89,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22755,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,MULTIPLAN,MULTIPLAN, 210.60,,OUTPCT LIMIT, 171.36,OTHER, 103.33, 229.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22756,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,MULTIPLAN,MULTIPLAN, 442.11,,OUTPCT LIMIT, 273.87,OTHER, 142.76, 481.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22757,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,MULTIPLAN,MULTIPLAN, 395.10,,OUTPCT LIMIT, 276.81,OTHER, 142.76, 430.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22758,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,MULTIPLAN,MULTIPLAN, 325.89,,OUTPCT LIMIT, 242.16,OTHER, 155.70, 354.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22759,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,MULTIPLAN,MULTIPLAN, 414.90,,OUTPCT LIMIT, 850.02,OTHER, 203.58, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22760,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,MULTIPLAN,MULTIPLAN, 395.10,,OUTPCT LIMIT, 667.92,OTHER, 193.86, 1237.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22761,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,MULTIPLAN,MULTIPLAN, 138.60,,OUTPCT LIMIT, 177.23,OTHER, 68.01, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22762,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,MULTIPLAN,MULTIPLAN, 63.00,,OUTPCT LIMIT, 131.69,OTHER, 30.91, 267.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22763,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,MULTIPLAN,MULTIPLAN, 114.30,,OUTPCT LIMIT, 116.49,OTHER, 56.08, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22764,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,MULTIPLAN,MULTIPLAN, 549.00,,OUTPCT LIMIT, 405.48,OTHER, 256.74, 597.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22765,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,MULTIPLAN,MULTIPLAN, 330.30,,OUTPCT LIMIT, 293.67,OTHER, 162.07, 359.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22766,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,MULTIPLAN,MULTIPLAN, 218.70,,OUTPCT LIMIT, 216.69,OTHER, 107.31, 256.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22767,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,MULTIPLAN,MULTIPLAN, 69.30,,OUTPCT LIMIT, 61.61,OTHER, 34.00, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22768,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,MULTIPLAN,MULTIPLAN, 123.30,,OUTPCT LIMIT, 233.68,OTHER, 60.50, 456.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22769,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,MULTIPLAN,MULTIPLAN, 188.10,,OUTPCT LIMIT, 158.67,OTHER, 92.29, 204.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22770,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,MULTIPLAN,MULTIPLAN, 143.10,,OUTPCT LIMIT, 112.58,OTHER, 70.21, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22771,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,MULTIPLAN,MULTIPLAN, 165.60,,OUTPCT LIMIT, 125.44,OTHER, 81.25, 180.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22772,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,MULTIPLAN,MULTIPLAN, 105.30,,OUTPCT LIMIT, 114.17,OTHER, 51.67, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22773,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,MULTIPLAN,MULTIPLAN, 124.20,,OUTPCT LIMIT, 122.15,OTHER, 60.94, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22774,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,MULTIPLAN,MULTIPLAN, 189.00,,OUTPCT LIMIT, 138.81,OTHER, 86.20, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22775,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,MULTIPLAN,MULTIPLAN, 151.20,,OUTPCT LIMIT, 117.21,OTHER, 74.19, 164.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22776,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,MULTIPLAN,MULTIPLAN, 184.50,,OUTPCT LIMIT, 258.26,OTHER, 90.53, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22777,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,MULTIPLAN,MULTIPLAN, 235.80,,OUTPCT LIMIT, 287.58,OTHER, 115.70, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22778,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,MULTIPLAN,MULTIPLAN, 317.70,,OUTPCT LIMIT, 334.39,OTHER, 155.88, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22779,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,MULTIPLAN,MULTIPLAN, 2147.40,,OUTPCT LIMIT, 1514.68,OTHER, 804.50, 2338.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22780,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,MULTIPLAN,MULTIPLAN, 1213.20,,OUTPCT LIMIT, 1306.30,OTHER, 595.28, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22781,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,MULTIPLAN,MULTIPLAN, 547.20,,OUTPCT LIMIT, 925.64,OTHER, 268.49, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22782,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,MULTIPLAN,MULTIPLAN, 179.10,,OUTPCT LIMIT, 389.69,OTHER, 87.88, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22783,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,MULTIPLAN,MULTIPLAN, 244.80,,OUTPCT LIMIT, 427.24,OTHER, 120.12, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22784,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,MULTIPLAN,MULTIPLAN, 297.90,,OUTPCT LIMIT, 457.59,OTHER, 146.17, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22785,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,MULTIPLAN,MULTIPLAN, 209.70,,OUTPCT LIMIT, 732.74,OTHER, 102.89, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22786,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,MULTIPLAN,MULTIPLAN, 611.10,,OUTPCT LIMIT, 1168.49,OTHER, 299.85, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22787,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,MULTIPLAN,MULTIPLAN, 258.30,,OUTPCT LIMIT, 300.44,OTHER, 126.74, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22788,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,MULTIPLAN,MULTIPLAN, 363.60,,OUTPCT LIMIT, 495.14,OTHER, 178.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22789,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,MULTIPLAN,MULTIPLAN, 432.90,,OUTPCT LIMIT, 534.75,OTHER, 212.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22790,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,MULTIPLAN,MULTIPLAN, 499.50,,OUTPCT LIMIT, 572.81,OTHER, 245.09, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22791,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,MULTIPLAN,MULTIPLAN, 445.50,,OUTPCT LIMIT, 541.95,OTHER, 218.59, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22792,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,MULTIPLAN,MULTIPLAN, 510.30,,OUTPCT LIMIT, 578.99,OTHER, 250.39, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22793,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,MULTIPLAN,MULTIPLAN, 1562.40,,OUTPCT LIMIT, 1505.88,OTHER, 766.62, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22794,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,MULTIPLAN,MULTIPLAN, 629.10,,OUTPCT LIMIT, 646.89,OTHER, 308.68, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22795,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,MULTIPLAN,MULTIPLAN, 740.70,,OUTPCT LIMIT, 1242.56,OTHER, 363.44, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22796,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,MULTIPLAN,MULTIPLAN, 395.10,,OUTPCT LIMIT, 513.14,OTHER, 193.86, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22797,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,MULTIPLAN,MULTIPLAN, 408.60,,OUTPCT LIMIT, 520.86,OTHER, 200.49, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22798,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,MULTIPLAN,MULTIPLAN, 712.80,,OUTPCT LIMIT, 694.73,OTHER, 349.75, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22799,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,MULTIPLAN,MULTIPLAN, 585.90,,OUTPCT LIMIT, 947.76,OTHER, 287.48, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22800,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,MULTIPLAN,MULTIPLAN, 1004.40,,OUTPCT LIMIT, 1393.28,OTHER, 492.83, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22801,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,MULTIPLAN,MULTIPLAN, 50.40,,OUTPCT LIMIT, 56.01,OTHER, 24.73, 76.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22802,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,MULTIPLAN,MULTIPLAN, 304.11,,OUTPCT LIMIT, 185.53,OTHER, 86.20, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22803,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,MULTIPLAN,MULTIPLAN, 116.35,,OUTPCT LIMIT, 97.29,OTHER, 57.09, 126.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22804,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,MULTIPLAN,MULTIPLAN, 116.10,,OUTPCT LIMIT, 97.14,OTHER, 56.97, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22805,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,MULTIPLAN,MULTIPLAN, 45.90,,OUTPCT LIMIT, 57.02,OTHER, 22.52, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22806,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,MULTIPLAN,MULTIPLAN, 385.20,,OUTPCT LIMIT, 372.97,OTHER, 189.00, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22807,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,MULTIPLAN,MULTIPLAN, 1098.00,,OUTPCT LIMIT, 1446.78,OTHER, 538.75, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22808,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,MULTIPLAN,MULTIPLAN, 529.20,,OUTPCT LIMIT, 1121.68,OTHER, 259.66, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22809,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,MULTIPLAN,MULTIPLAN, 345.37,,OUTPCT LIMIT, 278.63,OTHER, 165.01, 383.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22810,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,MULTIPLAN,MULTIPLAN, 619.96,,OUTPCT LIMIT, 427.61,OTHER, 296.20, 675.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22811,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,MULTIPLAN,MULTIPLAN, 375.17,,OUTPCT LIMIT, 237.66,OTHER, 143.26, 408.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22812,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,MULTIPLAN,MULTIPLAN, 404.64,,OUTPCT LIMIT, 253.66,OTHER, 143.26, 440.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22813,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,MULTIPLAN,MULTIPLAN, 438.75,,OUTPCT LIMIT, 272.17,OTHER, 143.26, 477.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22814,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,MULTIPLAN,MULTIPLAN, 400.47,,OUTPCT LIMIT, 251.39,OTHER, 143.26, 436.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22815,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,MULTIPLAN,MULTIPLAN, 368.10,,OUTPCT LIMIT, 261.55,OTHER, 143.26, 400.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22816,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,MULTIPLAN,MULTIPLAN, 424.73,,OUTPCT LIMIT, 264.56,OTHER, 143.26, 462.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22817,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,MULTIPLAN,MULTIPLAN, 429.03,,OUTPCT LIMIT, 306.35,OTHER, 204.98, 467.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22818,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,MULTIPLAN,MULTIPLAN, 765.90,,OUTPCT LIMIT, 548.12,OTHER, 309.01, 833.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22819,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,MULTIPLAN,MULTIPLAN, 442.80,,OUTPCT LIMIT, 300.52,OTHER, 132.82, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22820,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,MULTIPLAN,MULTIPLAN, 481.89,,OUTPCT LIMIT, 293.08,OTHER, 132.82, 524.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22821,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,MULTIPLAN,MULTIPLAN, 1751.27,,OUTPCT LIMIT, 1023.77,OTHER, 309.01, 1906.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22822,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,MULTIPLAN,MULTIPLAN, 678.60,,OUTPCT LIMIT, 498.22,OTHER, 309.01, 738.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22823,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,MULTIPLAN,MULTIPLAN, 2948.63,,OUTPCT LIMIT, 1703.49,OTHER, 435.32, 3210.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22824,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,MULTIPLAN,MULTIPLAN, 780.30,,OUTPCT LIMIT, 601.46,OTHER, 382.87, 849.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22825,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,MULTIPLAN,MULTIPLAN, 2432.70,,OUTPCT LIMIT, 2228.68,OTHER, 1193.64, 2648.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22826,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,MULTIPLAN,MULTIPLAN, 2642.40,,OUTPCT LIMIT, 2329.49,OTHER, 1296.54, 2877.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22827,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,MULTIPLAN,MULTIPLAN, 115.20,,OUTPCT LIMIT, 163.86,OTHER, 56.52, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22828,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,MULTIPLAN,MULTIPLAN, 304.11,,OUTPCT LIMIT, 200.99,OTHER, 145.30, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22829,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,MULTIPLAN,MULTIPLAN, 108.90,,OUTPCT LIMIT, 93.03,OTHER, 53.43, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22830,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,MULTIPLAN,MULTIPLAN, 11.70,,OUTPCT LIMIT, 22.22,OTHER, 5.74, 43.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22831,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,MULTIPLAN,MULTIPLAN, 298.80,,OUTPCT LIMIT, 224.77,OTHER, 146.61, 325.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22832,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,MULTIPLAN,MULTIPLAN, 158.40,,OUTPCT LIMIT, 251.63,OTHER, 77.72, 451.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22833,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,MULTIPLAN,MULTIPLAN, 492.30,,OUTPCT LIMIT, 1148.36,OTHER, 241.56, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22834,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,MULTIPLAN,MULTIPLAN, 1167.30,,OUTPCT LIMIT, 1534.16,OTHER, 572.76, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22835,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,MULTIPLAN,MULTIPLAN, 249.30,,OUTPCT LIMIT, 232.01,OTHER, 122.32, 271.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22836,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,MULTIPLAN,MULTIPLAN, 119.34,,OUTPCT LIMIT, 124.43,OTHER, 57.02, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22837,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,MULTIPLAN,MULTIPLAN, 111.60,,OUTPCT LIMIT, 120.23,OTHER, 53.32, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22838,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,MULTIPLAN,MULTIPLAN, 130.05,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22839,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,MULTIPLAN,MULTIPLAN, 130.05,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22840,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,MULTIPLAN,MULTIPLAN, 7673.40,,OUTPCT LIMIT, 5204.99,OTHER, 2293.79, 8355.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22841,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,MULTIPLAN,MULTIPLAN, 559.80,,OUTPCT LIMIT, 932.84,OTHER, 274.68, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22842,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,MULTIPLAN,MULTIPLAN, 711.18,,OUTPCT LIMIT, 424.57,OTHER, 162.56, 774.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22843,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,MULTIPLAN,MULTIPLAN, 545.90,,OUTPCT LIMIT, 334.89,OTHER, 162.56, 594.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22844,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,MULTIPLAN,MULTIPLAN, 1039.35,,OUTPCT LIMIT, 675.88,OTHER, 470.23, 1131.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22845,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,MULTIPLAN,MULTIPLAN, 849.78,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22846,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,MULTIPLAN,MULTIPLAN, 849.78,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22847,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,MULTIPLAN,MULTIPLAN, 311.45,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22848,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,MULTIPLAN,MULTIPLAN, 311.45,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22849,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,MULTIPLAN,MULTIPLAN, 280.32,,OUTPCT LIMIT, 176.70,OTHER, 103.34, 305.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22850,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,MULTIPLAN,MULTIPLAN, 1016.96,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22851,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,MULTIPLAN,MULTIPLAN, 1016.96,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22852,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,MULTIPLAN,MULTIPLAN, 1769.35,,OUTPCT LIMIT, 1089.64,OTHER, 544.52, 1926.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22853,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,MULTIPLAN,MULTIPLAN, 31.50,,OUTPCT LIMIT, 22.43,OTHER, 15.05, 34.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22854,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,MULTIPLAN,MULTIPLAN, 27.95,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22855,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,MULTIPLAN,MULTIPLAN, 27.95,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22856,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,MULTIPLAN,MULTIPLAN, 27.95,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22857,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,MULTIPLAN,MULTIPLAN, 27.95,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22858,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,MULTIPLAN,MULTIPLAN, 27.95,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22859,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,MULTIPLAN,MULTIPLAN, 27.95,,OUTPCT LIMIT, 20.38,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22860,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,MULTIPLAN,MULTIPLAN, 22.50,,OUTPCT LIMIT, 16.02,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22861,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,MULTIPLAN,MULTIPLAN, 921.70,,OUTPCT LIMIT, 579.04,OTHER, 331.58, 1003.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22862,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,MULTIPLAN,MULTIPLAN, 1985.40,,OUTPCT LIMIT, 1525.88,OTHER, 974.17, 2161.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22863,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,MULTIPLAN,MULTIPLAN, 5616.00,,OUTPCT LIMIT, 4097.24,OTHER, 2484.68, 6115.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22864,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,MULTIPLAN,MULTIPLAN, 5973.30,,OUTPCT LIMIT, 4480.28,OTHER, 2930.90, 6504.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22865,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,MULTIPLAN,MULTIPLAN, 738.90,,OUTPCT LIMIT, 813.44,OTHER, 362.55, 1095.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22866,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,MULTIPLAN,MULTIPLAN, 6472.80,,OUTPCT LIMIT, 4090.68,OTHER, 1095.12, 7048.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22867,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,MULTIPLAN,MULTIPLAN, 217.43,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22868,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,MULTIPLAN,MULTIPLAN, 217.43,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22869,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,MULTIPLAN,MULTIPLAN, 568.80,,OUTPCT LIMIT, 1187.28,OTHER, 279.09, 2414.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22870,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,MULTIPLAN,MULTIPLAN, 351.90,,OUTPCT LIMIT, 803.17,OTHER, 172.67, 1685.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22871,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,MULTIPLAN,MULTIPLAN, 1979.10,,OUTPCT LIMIT, 1733.21,OTHER, 971.08, 2155.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22872,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,MULTIPLAN,MULTIPLAN, 2539.80,,OUTPCT LIMIT, 1757.99,OTHER, 857.80, 2765.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22873,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,MULTIPLAN,MULTIPLAN, 299.70,,OUTPCT LIMIT, 477.65,OTHER, 147.05, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22874,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,MULTIPLAN,MULTIPLAN, 334.80,,OUTPCT LIMIT, 497.71,OTHER, 164.28, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22875,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,MULTIPLAN,MULTIPLAN, 2114.10,,OUTPCT LIMIT, 1514.68,OTHER, 857.80, 2302.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22876,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,MULTIPLAN,MULTIPLAN, 2987.10,,OUTPCT LIMIT, 2013.65,OTHER, 857.80, 3252.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22877,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,MULTIPLAN,MULTIPLAN, 425.70,,OUTPCT LIMIT, 549.67,OTHER, 208.88, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22878,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,MULTIPLAN,MULTIPLAN, 476.10,,OUTPCT LIMIT, 578.48,OTHER, 233.61, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22879,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,MULTIPLAN,MULTIPLAN, 2480.40,,OUTPCT LIMIT, 2205.29,OTHER, 1217.05, 2700.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22880,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,MULTIPLAN,MULTIPLAN, 3037.50,,OUTPCT LIMIT, 2700.60,OTHER, 1490.40, 3307.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22881,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,MULTIPLAN,MULTIPLAN, 1049.61,,OUTPCT LIMIT, 718.33,OTHER, 501.48, 1142.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22882,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,MULTIPLAN,MULTIPLAN, 2741.40,,OUTPCT LIMIT, 2437.34,OTHER, 1345.11, 2985.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22883,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,MULTIPLAN,MULTIPLAN, 1449.90,,OUTPCT LIMIT, 1780.93,OTHER, 711.42, 2666.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22884,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,MULTIPLAN,MULTIPLAN, 1349.10,,OUTPCT LIMIT, 2411.76,OTHER, 661.96, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22885,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,MULTIPLAN,MULTIPLAN, 142.20,,OUTPCT LIMIT, 283.55,OTHER, 69.77, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22886,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,MULTIPLAN,MULTIPLAN, 169.20,,OUTPCT LIMIT, 298.98,OTHER, 83.02, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22887,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,MULTIPLAN,MULTIPLAN, 278.10,,OUTPCT LIMIT, 482.77,OTHER, 136.45, 906.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22888,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,MULTIPLAN,MULTIPLAN, 498.60,,OUTPCT LIMIT, 603.90,OTHER, 244.65, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22889,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,MULTIPLAN,MULTIPLAN, 584.10,,OUTPCT LIMIT, 652.77,OTHER, 286.60, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22890,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,MULTIPLAN,MULTIPLAN, 761.40,,OUTPCT LIMIT, 754.11,OTHER, 373.59, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22891,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,MULTIPLAN,MULTIPLAN, 694.80,,OUTPCT LIMIT, 716.04,OTHER, 340.92, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22892,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,MULTIPLAN,MULTIPLAN, 669.60,,OUTPCT LIMIT, 701.64,OTHER, 328.55, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22893,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,MULTIPLAN,MULTIPLAN, 3422.70,,OUTPCT LIMIT, 2366.55,OTHER, 1148.80, 3726.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22894,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,MULTIPLAN,MULTIPLAN, 225.90,,OUTPCT LIMIT, 623.49,OTHER, 110.84, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22895,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,MULTIPLAN,MULTIPLAN, 324.90,,OUTPCT LIMIT, 256.43,OTHER, 159.42, 353.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22896,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,MULTIPLAN,MULTIPLAN, 250.20,,OUTPCT LIMIT, 637.38,OTHER, 122.76, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22897,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,MULTIPLAN,MULTIPLAN, 250.20,,OUTPCT LIMIT, 982.61,OTHER, 122.76, 2350.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22898,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,MULTIPLAN,MULTIPLAN, 1333.80,,OUTPCT LIMIT, 1507.20,OTHER, 654.45, 2085.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22899,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,MULTIPLAN,MULTIPLAN, 3368.70,,OUTPCT LIMIT, 3143.54,OTHER, 1652.91, 3668.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22900,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,MULTIPLAN,MULTIPLAN, 1479.60,,OUTPCT LIMIT, 2486.35,OTHER, 725.99, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22901,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,MULTIPLAN,MULTIPLAN, 1608.30,,OUTPCT LIMIT, 2559.90,OTHER, 789.14, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22902,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,MULTIPLAN,MULTIPLAN, 1602.90,,OUTPCT LIMIT, 1425.12,OTHER, 786.49, 1745.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22903,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,MULTIPLAN,MULTIPLAN, 2579.40,,OUTPCT LIMIT, 1667.02,OTHER, 539.71, 2808.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22904,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,MULTIPLAN,MULTIPLAN, 1166.40,,OUTPCT LIMIT, 1786.42,OTHER, 572.31, 3135.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22905,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,MULTIPLAN,MULTIPLAN, 3187.80,,OUTPCT LIMIT, 3662.54,OTHER, 1564.15, 5153.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22906,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,MULTIPLAN,MULTIPLAN, 329.40,,OUTPCT LIMIT, 889.66,OTHER, 161.63, 1963.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22907,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,MULTIPLAN,MULTIPLAN, 362.66,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22908,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,MULTIPLAN,MULTIPLAN, 362.66,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22909,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,MULTIPLAN,MULTIPLAN, 2451.60,,OUTPCT LIMIT, 2146.09,OTHER, 1202.92, 2669.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22910,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 199.77,OTHER, 96.75, 377.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22911,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 266.50,OTHER, 96.75, 657.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22912,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,MULTIPLAN,MULTIPLAN, 3094.20,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22913,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,MULTIPLAN,MULTIPLAN, 3094.20,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22914,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,MULTIPLAN,MULTIPLAN, 1010.57,,OUTPCT LIMIT, 719.65,OTHER, 482.83, 1100.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22915,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,MULTIPLAN,MULTIPLAN, 1807.70,,OUTPCT LIMIT, 1287.31,OTHER, 863.68, 1968.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22916,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,MULTIPLAN,MULTIPLAN, 408.51,,OUTPCT LIMIT, 290.91,OTHER, 195.18, 444.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22917,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,MULTIPLAN,MULTIPLAN, 1524.60,,OUTPCT LIMIT, 2579.17,OTHER, 748.07, 4781.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22918,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,MULTIPLAN,MULTIPLAN, 235.01,,OUTPCT LIMIT, 162.43,OTHER, 112.28, 255.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22919,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,MULTIPLAN,MULTIPLAN, 203.47,,OUTPCT LIMIT, 145.32,OTHER, 97.21, 221.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22920,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,MULTIPLAN,MULTIPLAN, 129.96,,OUTPCT LIMIT, 116.13,OTHER, 62.09, 191.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22921,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,MULTIPLAN,MULTIPLAN, 107.10,,OUTPCT LIMIT, 76.24,OTHER, 51.17, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22922,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,MULTIPLAN,MULTIPLAN, 191.75,,OUTPCT LIMIT, 124.60,OTHER, 86.34, 208.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22923,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22924,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MULTIPLAN,MULTIPLAN, 77.40,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22925,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22926,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,MULTIPLAN,MULTIPLAN, 123.30,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22927,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22928,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MULTIPLAN,MULTIPLAN, 236.93,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22929,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22930,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MULTIPLAN,MULTIPLAN, 77.40,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22931,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22932,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,MULTIPLAN,MULTIPLAN, 256.29,,OUTPCT LIMIT, 171.96,OTHER, 122.45, 279.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22933,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22934,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,MULTIPLAN,MULTIPLAN, 197.55,,OUTPCT LIMIT, 127.74,OTHER, 86.34, 215.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22935,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22936,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,MULTIPLAN,MULTIPLAN, 288.77,,OUTPCT LIMIT, 189.58,OTHER, 137.97, 314.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22937,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22938,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,MULTIPLAN,MULTIPLAN, 177.60,,OUTPCT LIMIT, 116.92,OTHER, 84.85, 193.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22939,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22940,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,MULTIPLAN,MULTIPLAN, 491.43,,OUTPCT LIMIT, 299.54,OTHER, 138.19, 535.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22941,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22942,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,MULTIPLAN,MULTIPLAN, 346.75,,OUTPCT LIMIT, 221.04,OTHER, 138.19, 377.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22943,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22944,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MULTIPLAN,MULTIPLAN, 266.40,,OUTPCT LIMIT, 177.44,OTHER, 127.28, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22945,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22946,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,MULTIPLAN,MULTIPLAN, 93.36,,OUTPCT LIMIT, 71.21,OTHER, 44.60, 101.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22947,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22948,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,MULTIPLAN,MULTIPLAN, 318.85,,OUTPCT LIMIT, 193.56,OTHER, 86.34, 347.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22949,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22950,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,MULTIPLAN,MULTIPLAN, 374.04,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22951,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MULTIPLAN,MULTIPLAN, 2635.33,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22952,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,MULTIPLAN,MULTIPLAN, 1958.83,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22953,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22954,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22955,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,MULTIPLAN,MULTIPLAN, 2014.74,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22956,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,MULTIPLAN,MULTIPLAN, 2014.74,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22957,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22958,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22959,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MULTIPLAN,MULTIPLAN, 2635.33,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22960,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,MULTIPLAN,MULTIPLAN, 2635.33,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22961,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22962,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22963,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,MULTIPLAN,MULTIPLAN, 1635.96,,OUTPCT LIMIT, 955.20,OTHER, 283.82, 1781.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22964,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22965,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,MULTIPLAN,MULTIPLAN, 1084.55,,OUTPCT LIMIT, 691.35,OTHER, 432.18, 1180.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22966,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22967,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,MULTIPLAN,MULTIPLAN, 1422.00,,OUTPCT LIMIT, 887.08,OTHER, 485.27, 1548.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22968,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22969,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,MULTIPLAN,MULTIPLAN, 1536.30,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22970,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,MULTIPLAN,MULTIPLAN, 1536.64,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22971,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22972,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22973,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,MULTIPLAN,MULTIPLAN, 1756.50,,OUTPCT LIMIT, 1055.93,OTHER, 432.18, 1912.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22974,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,MULTIPLAN,MULTIPLAN, 2211.29,,OUTPCT LIMIT, 1302.68,OTHER, 432.18, 2407.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22975,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22976,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22977,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,MULTIPLAN,MULTIPLAN, 732.60,,OUTPCT LIMIT, 513.03,OTHER, 350.02, 797.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22978,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22979,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,MULTIPLAN,MULTIPLAN, 2254.10,,OUTPCT LIMIT, 1290.59,OTHER, 283.82, 2454.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22980,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22981,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,MULTIPLAN,MULTIPLAN, 2344.23,,OUTPCT LIMIT, 1374.81,OTHER, 432.18, 2552.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22982,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22983,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,MULTIPLAN,MULTIPLAN, 2120.31,,OUTPCT LIMIT, 1265.96,OTHER, 485.27, 2308.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22984,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22985,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MULTIPLAN,MULTIPLAN, 1766.03,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22986,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MULTIPLAN,MULTIPLAN, 1766.03,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22987,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,MULTIPLAN,MULTIPLAN, 1766.03,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22988,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22989,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22990,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22991,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,MULTIPLAN,MULTIPLAN, 2124.81,,OUTPCT LIMIT, 1270.81,OTHER, 495.38, 2313.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22992,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22993,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,MULTIPLAN,MULTIPLAN, 2757.30,,OUTPCT LIMIT, 1681.52,OTHER, 779.04, 3002.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22994,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22995,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,MULTIPLAN,MULTIPLAN, 2034.35,,OUTPCT LIMIT, 1224.87,OTHER, 508.57, 2215.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22996,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22997,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,MULTIPLAN,MULTIPLAN, 2169.90,,OUTPCT LIMIT, 1324.21,OTHER, 616.91, 2362.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22998,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 22999,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,MULTIPLAN,MULTIPLAN, 2483.55,,OUTPCT LIMIT, 1532.99,OTHER, 779.04, 2704.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23000,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23001,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,MULTIPLAN,MULTIPLAN, 2050.43,,OUTPCT LIMIT, 1233.59,OTHER, 508.57, 2232.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23002,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23003,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,MULTIPLAN,MULTIPLAN, 2044.80,,OUTPCT LIMIT, 1256.33,OTHER, 616.91, 2226.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23004,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23005,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,MULTIPLAN,MULTIPLAN, 2351.03,,OUTPCT LIMIT, 1461.09,OTHER, 779.04, 2560.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23006,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23007,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,MULTIPLAN,MULTIPLAN, 2382.31,,OUTPCT LIMIT, 1413.66,OTHER, 508.57, 2594.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23008,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23009,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,MULTIPLAN,MULTIPLAN, 3678.23,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23010,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,MULTIPLAN,MULTIPLAN, 3678.23,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23011,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23012,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23013,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MULTIPLAN,MULTIPLAN, 77.40,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23014,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MULTIPLAN,MULTIPLAN, 77.40,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23015,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MULTIPLAN,MULTIPLAN, 77.40,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23016,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MULTIPLAN,MULTIPLAN, 77.40,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23017,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23018,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23019,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23020,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23021,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MULTIPLAN,MULTIPLAN, 77.40,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23022,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23023,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MULTIPLAN,MULTIPLAN, 77.40,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23024,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MULTIPLAN,MULTIPLAN, 77.40,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23025,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23026,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23027,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,MULTIPLAN,MULTIPLAN, 408.23,,OUTPCT LIMIT, 242.05,OTHER, 86.34, 444.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23028,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,MULTIPLAN,MULTIPLAN, 410.93,,OUTPCT LIMIT, 243.52,OTHER, 86.34, 447.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23029,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23030,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23031,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,MULTIPLAN,MULTIPLAN, 334.03,,OUTPCT LIMIT, 214.14,OTHER, 138.19, 363.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23032,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,MULTIPLAN,MULTIPLAN, 381.74,,OUTPCT LIMIT, 240.03,OTHER, 138.19, 415.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23033,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23034,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23035,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,MULTIPLAN,MULTIPLAN, 398.04,,OUTPCT LIMIT, 248.87,OTHER, 138.19, 433.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23036,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23037,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MULTIPLAN,MULTIPLAN, 266.40,,OUTPCT LIMIT, 165.10,OTHER, 86.34, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23038,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23039,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MULTIPLAN,MULTIPLAN, 77.40,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23040,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23041,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MULTIPLAN,MULTIPLAN, 2108.16,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23042,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MULTIPLAN,MULTIPLAN, 2108.16,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23043,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MULTIPLAN,MULTIPLAN, 2108.16,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23044,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23045,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23046,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MULTIPLAN,MULTIPLAN, 2108.16,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23047,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,MULTIPLAN,MULTIPLAN, 2514.17,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23048,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23049,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,MULTIPLAN,MULTIPLAN, 3136.37,,OUTPCT LIMIT, 1817.25,OTHER, 485.27, 3415.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23050,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23051,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MULTIPLAN,MULTIPLAN, 2108.16,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23052,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MULTIPLAN,MULTIPLAN, 2108.16,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23053,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,MULTIPLAN,MULTIPLAN, 2108.16,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23054,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23055,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23056,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23057,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,MULTIPLAN,MULTIPLAN, 4482.03,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23058,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MULTIPLAN,MULTIPLAN, 3020.11,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23059,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MULTIPLAN,MULTIPLAN, 3020.11,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23060,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MULTIPLAN,MULTIPLAN, 3020.11,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23061,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,MULTIPLAN,MULTIPLAN, 3020.11,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23062,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23063,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23064,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23065,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23066,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,MULTIPLAN,MULTIPLAN, 1139.40,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23067,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,MULTIPLAN,MULTIPLAN, 2542.50,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23068,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23069,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23070,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,MULTIPLAN,MULTIPLAN, 273.60,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23071,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,MULTIPLAN,MULTIPLAN, 273.60,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23072,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23073,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23074,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,MULTIPLAN,MULTIPLAN, 395.80,,OUTPCT LIMIT, 247.65,OTHER, 138.19, 430.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23075,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23076,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,MULTIPLAN,MULTIPLAN, 585.54,,OUTPCT LIMIT, 350.60,OTHER, 138.19, 637.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23077,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23078,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,MULTIPLAN,MULTIPLAN, 644.57,,OUTPCT LIMIT, 382.63,OTHER, 138.19, 701.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23079,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23080,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,MULTIPLAN,MULTIPLAN, 480.29,,OUTPCT LIMIT, 293.50,OTHER, 138.19, 522.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23081,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23082,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,MULTIPLAN,MULTIPLAN, 429.35,,OUTPCT LIMIT, 265.86,OTHER, 138.19, 467.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23083,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23084,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MULTIPLAN,MULTIPLAN, 236.93,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23085,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23086,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,MULTIPLAN,MULTIPLAN, 225.00,,OUTPCT LIMIT, 142.64,OTHER, 86.34, 245.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23087,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23088,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,MULTIPLAN,MULTIPLAN, 77.40,,OUTPCT LIMIT, 63.06,OTHER, 36.98, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23089,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,MULTIPLAN,MULTIPLAN, 236.93,,OUTPCT LIMIT, 163.44,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23090,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23091,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,MULTIPLAN,MULTIPLAN, 417.15,,OUTPCT LIMIT, 259.24,OTHER, 138.19, 454.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23092,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23093,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,MULTIPLAN,MULTIPLAN, 246.98,,OUTPCT LIMIT, 166.91,OTHER, 118.00, 268.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23094,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23095,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,MULTIPLAN,MULTIPLAN, 689.64,,OUTPCT LIMIT, 407.08,OTHER, 138.19, 750.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23096,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23097,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MULTIPLAN,MULTIPLAN, 2565.19,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23098,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MULTIPLAN,MULTIPLAN, 2565.19,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23099,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,MULTIPLAN,MULTIPLAN, 2565.19,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23100,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23101,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23102,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23103,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,MULTIPLAN,MULTIPLAN, 1012.50,,OUTPCT LIMIT, 664.89,OTHER, 483.75, 1102.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23104,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23105,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,MULTIPLAN,MULTIPLAN, 2914.88,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23106,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,MULTIPLAN,MULTIPLAN, 2914.88,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23107,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23108,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23109,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,MULTIPLAN,MULTIPLAN, 2880.00,,OUTPCT LIMIT, 1665.51,OTHER, 432.18, 3136.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23110,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23111,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,MULTIPLAN,MULTIPLAN, 2527.97,,OUTPCT LIMIT, 1439.18,OTHER, 283.82, 2752.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23112,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23113,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,MULTIPLAN,MULTIPLAN, 2856.19,,OUTPCT LIMIT, 1652.58,OTHER, 432.18, 3110.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23114,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23115,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,MULTIPLAN,MULTIPLAN, 2700.00,,OUTPCT LIMIT, 1580.48,OTHER, 485.27, 2940.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23116,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23117,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,MULTIPLAN,MULTIPLAN, 2932.71,,OUTPCT LIMIT, 1712.29,OTHER, 508.57, 3193.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23118,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23119,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,MULTIPLAN,MULTIPLAN, 3269.05,,OUTPCT LIMIT, 1894.78,OTHER, 508.57, 3559.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23120,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23121,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,MULTIPLAN,MULTIPLAN, 2869.38,,OUTPCT LIMIT, 1677.93,OTHER, 508.57, 3124.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23122,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23123,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,MULTIPLAN,MULTIPLAN, 3565.08,,OUTPCT LIMIT, 2119.80,OTHER, 779.04, 3881.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23124,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23125,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,MULTIPLAN,MULTIPLAN, 4338.69,,OUTPCT LIMIT, 2539.54,OTHER, 779.04, 4724.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23126,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23127,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,MULTIPLAN,MULTIPLAN, 4063.45,,OUTPCT LIMIT, 2390.20,OTHER, 779.04, 4424.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23128,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23129,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23130,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23131,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23132,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,MULTIPLAN,MULTIPLAN, 375.82,,OUTPCT LIMIT, 236.81,OTHER, 138.19, 409.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23133,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23134,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,MULTIPLAN,MULTIPLAN, 296.67,,OUTPCT LIMIT, 193.87,OTHER, 138.19, 323.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23135,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23136,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,MULTIPLAN,MULTIPLAN, 2199.86,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23137,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,MULTIPLAN,MULTIPLAN, 2199.86,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23138,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23139,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23140,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,MULTIPLAN,MULTIPLAN, 2125.44,,OUTPCT LIMIT, 1256.10,OTHER, 432.18, 2314.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23141,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23142,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,MULTIPLAN,MULTIPLAN, 1435.95,,OUTPCT LIMIT, 894.65,OTHER, 485.27, 1563.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23143,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23144,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,MULTIPLAN,MULTIPLAN, 3005.02,,OUTPCT LIMIT, 1751.53,OTHER, 508.57, 3272.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23145,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23146,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,MULTIPLAN,MULTIPLAN, 4504.23,,OUTPCT LIMIT, 2629.35,OTHER, 779.04, 4904.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23147,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23148,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MULTIPLAN,MULTIPLAN, 1800.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23149,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MULTIPLAN,MULTIPLAN, 1800.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23150,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,MULTIPLAN,MULTIPLAN, 1800.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23151,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23152,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23153,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23154,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,MULTIPLAN,MULTIPLAN, 264.72,,OUTPCT LIMIT, 164.19,OTHER, 86.34, 288.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23155,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23156,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,MULTIPLAN,MULTIPLAN, 375.61,,OUTPCT LIMIT, 224.35,OTHER, 86.34, 408.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23157,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23158,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,MULTIPLAN,MULTIPLAN, 346.78,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23159,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,MULTIPLAN,MULTIPLAN, 346.78,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23160,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,MULTIPLAN,MULTIPLAN, 359.69,,OUTPCT LIMIT, 215.71,OTHER, 86.34, 391.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23161,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23162,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23163,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23164,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,MULTIPLAN,MULTIPLAN, 236.93,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23165,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,MULTIPLAN,MULTIPLAN, 236.93,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23166,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,MULTIPLAN,MULTIPLAN, 236.93,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23167,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23168,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23169,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23170,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,MULTIPLAN,MULTIPLAN, 286.20,,OUTPCT LIMIT, 175.84,OTHER, 86.34, 311.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23171,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,MULTIPLAN,MULTIPLAN, 273.70,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23172,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,MULTIPLAN,MULTIPLAN, 273.70,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23173,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23174,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23175,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23176,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,MULTIPLAN,MULTIPLAN, 372.60,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23177,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,MULTIPLAN,MULTIPLAN, 372.60,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23178,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,MULTIPLAN,MULTIPLAN, 382.36,,OUTPCT LIMIT, 240.36,OTHER, 138.19, 416.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23179,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23180,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23181,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23182,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,MULTIPLAN,MULTIPLAN, 367.04,,OUTPCT LIMIT, 219.70,OTHER, 86.34, 399.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23183,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,MULTIPLAN,MULTIPLAN, 357.36,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23184,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,MULTIPLAN,MULTIPLAN, 357.36,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23185,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23186,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23187,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23188,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,MULTIPLAN,MULTIPLAN, 342.81,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23189,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,MULTIPLAN,MULTIPLAN, 352.49,,OUTPCT LIMIT, 211.81,OTHER, 86.34, 383.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23190,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,MULTIPLAN,MULTIPLAN, 342.81,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23191,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23192,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23193,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23194,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,MULTIPLAN,MULTIPLAN, 386.10,,OUTPCT LIMIT, 230.04,OTHER, 86.34, 420.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23195,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,MULTIPLAN,MULTIPLAN, 374.04,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23196,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23197,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23198,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23199,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,MULTIPLAN,MULTIPLAN, 387.54,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23200,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,MULTIPLAN,MULTIPLAN, 387.54,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23201,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,MULTIPLAN,MULTIPLAN, 399.60,,OUTPCT LIMIT, 237.37,OTHER, 86.34, 435.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23202,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23203,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23204,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23205,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,MULTIPLAN,MULTIPLAN, 123.30,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23206,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,MULTIPLAN,MULTIPLAN, 171.00,,OUTPCT LIMIT, 125.68,OTHER, 81.70, 186.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23207,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,MULTIPLAN,MULTIPLAN, 123.30,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23208,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23209,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23210,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23211,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,MULTIPLAN,MULTIPLAN, 356.04,,OUTPCT LIMIT, 213.73,OTHER, 86.34, 387.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23212,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,MULTIPLAN,MULTIPLAN, 344.98,,OUTPCT LIMIT, 207.73,OTHER, 86.34, 375.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23213,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,MULTIPLAN,MULTIPLAN, 344.99,,OUTPCT LIMIT, 207.74,OTHER, 86.34, 375.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23214,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23215,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23216,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23217,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,MULTIPLAN,MULTIPLAN, 401.10,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23218,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,MULTIPLAN,MULTIPLAN, 410.79,,OUTPCT LIMIT, 243.44,OTHER, 86.34, 447.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23219,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,MULTIPLAN,MULTIPLAN, 401.10,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23220,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23221,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23222,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23223,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,MULTIPLAN,MULTIPLAN, 378.90,,OUTPCT LIMIT, 238.48,OTHER, 138.19, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23224,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,MULTIPLAN,MULTIPLAN, 366.84,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23225,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,MULTIPLAN,MULTIPLAN, 366.84,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23226,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23227,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23228,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23229,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,MULTIPLAN,MULTIPLAN, 368.24,,OUTPCT LIMIT, 220.36,OTHER, 86.34, 400.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23230,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,MULTIPLAN,MULTIPLAN, 368.36,,OUTPCT LIMIT, 220.42,OTHER, 86.34, 401.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23231,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,MULTIPLAN,MULTIPLAN, 378.04,,OUTPCT LIMIT, 225.67,OTHER, 86.34, 411.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23232,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23233,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23234,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23235,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,MULTIPLAN,MULTIPLAN, 306.81,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23236,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,MULTIPLAN,MULTIPLAN, 284.09,,OUTPCT LIMIT, 174.69,OTHER, 86.34, 309.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23237,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MULTIPLAN,MULTIPLAN, 274.41,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23238,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MULTIPLAN,MULTIPLAN, 274.41,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23239,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MULTIPLAN,MULTIPLAN, 274.41,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23240,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MULTIPLAN,MULTIPLAN, 274.41,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23241,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MULTIPLAN,MULTIPLAN, 274.41,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23242,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MULTIPLAN,MULTIPLAN, 274.41,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23243,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MULTIPLAN,MULTIPLAN, 274.41,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23244,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MULTIPLAN,MULTIPLAN, 274.41,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23245,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,MULTIPLAN,MULTIPLAN, 274.41,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23246,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,MULTIPLAN,MULTIPLAN, 274.41,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23247,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,MULTIPLAN,MULTIPLAN, 274.41,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23248,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23249,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23250,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23251,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23252,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23253,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23254,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23255,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23256,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23257,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23258,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23259,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23260,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23261,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,MULTIPLAN,MULTIPLAN, 1702.50,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23262,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,MULTIPLAN,MULTIPLAN, 1831.07,,OUTPCT LIMIT, 1061.06,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23263,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MULTIPLAN,MULTIPLAN, 1831.07,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23264,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MULTIPLAN,MULTIPLAN, 1831.07,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23265,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MULTIPLAN,MULTIPLAN, 1831.07,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23266,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MULTIPLAN,MULTIPLAN, 1831.07,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23267,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MULTIPLAN,MULTIPLAN, 1831.07,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23268,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,MULTIPLAN,MULTIPLAN, 602.10,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23269,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,MULTIPLAN,MULTIPLAN, 602.10,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23270,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MULTIPLAN,MULTIPLAN, 1831.07,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23271,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MULTIPLAN,MULTIPLAN, 1831.07,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23272,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,MULTIPLAN,MULTIPLAN, 602.10,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23273,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,MULTIPLAN,MULTIPLAN, 1831.07,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23274,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,MULTIPLAN,MULTIPLAN, 1831.07,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23275,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,MULTIPLAN,MULTIPLAN, 1702.50,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23276,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23277,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23278,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23279,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23280,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23281,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23282,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23283,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23284,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23285,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23286,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23287,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23288,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23289,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23290,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,MULTIPLAN,MULTIPLAN, 2546.09,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23291,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,MULTIPLAN,MULTIPLAN, 2546.09,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23292,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23293,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23294,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23295,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,MULTIPLAN,MULTIPLAN, 1214.10,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23296,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,MULTIPLAN,MULTIPLAN, 1214.10,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23297,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23298,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23299,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,MULTIPLAN,MULTIPLAN, 1722.29,,OUTPCT LIMIT, 1055.55,OTHER, 508.57, 1875.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23300,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23301,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,MULTIPLAN,MULTIPLAN, 2970.23,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23302,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,MULTIPLAN,MULTIPLAN, 2970.23,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23303,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,MULTIPLAN,MULTIPLAN, 2970.23,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23304,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23305,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23306,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23307,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MULTIPLAN,MULTIPLAN, 3028.20,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23308,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MULTIPLAN,MULTIPLAN, 3028.20,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23309,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MULTIPLAN,MULTIPLAN, 3028.20,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23310,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MULTIPLAN,MULTIPLAN, 3028.20,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23311,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MULTIPLAN,MULTIPLAN, 3028.20,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23312,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MULTIPLAN,MULTIPLAN, 3028.20,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23313,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MULTIPLAN,MULTIPLAN, 3028.20,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23314,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MULTIPLAN,MULTIPLAN, 3028.20,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23315,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MULTIPLAN,MULTIPLAN, 3028.20,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23316,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MULTIPLAN,MULTIPLAN, 3028.20,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23317,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MULTIPLAN,MULTIPLAN, 3028.20,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23318,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MULTIPLAN,MULTIPLAN, 3028.20,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23319,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MULTIPLAN,MULTIPLAN, 3028.20,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23320,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MULTIPLAN,MULTIPLAN, 3028.20,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23321,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,MULTIPLAN,MULTIPLAN, 3028.20,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23322,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,MULTIPLAN,MULTIPLAN, 3028.20,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23323,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23324,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23325,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23326,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23327,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23328,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23329,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23330,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23331,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23332,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23333,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23334,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23335,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23336,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23337,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23338,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23339,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,MULTIPLAN,MULTIPLAN, 2331.23,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23340,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,MULTIPLAN,MULTIPLAN, 2331.23,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23341,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23342,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23343,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23344,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23345,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23346,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23347,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,MULTIPLAN,MULTIPLAN, 324.25,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23348,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,MULTIPLAN,MULTIPLAN, 324.25,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23349,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,MULTIPLAN,MULTIPLAN, 324.25,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23350,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23351,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23352,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23353,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MULTIPLAN,MULTIPLAN, 313.17,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23354,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,MULTIPLAN,MULTIPLAN, 313.17,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23355,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MULTIPLAN,MULTIPLAN, 313.17,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23356,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,MULTIPLAN,MULTIPLAN, 313.17,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23357,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,MULTIPLAN,MULTIPLAN, 313.17,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23358,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23359,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23360,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23361,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23362,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,MULTIPLAN,MULTIPLAN, 409.66,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23363,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,MULTIPLAN,MULTIPLAN, 325.77,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23364,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23365,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23366,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,MULTIPLAN,MULTIPLAN, 335.29,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23367,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,MULTIPLAN,MULTIPLAN, 335.29,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23368,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,MULTIPLAN,MULTIPLAN, 344.96,,OUTPCT LIMIT, 208.23,OTHER, 88.46, 375.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23369,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23370,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23371,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23372,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,MULTIPLAN,MULTIPLAN, 350.50,,OUTPCT LIMIT, 210.73,OTHER, 86.34, 381.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23373,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,MULTIPLAN,MULTIPLAN, 339.44,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23374,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,MULTIPLAN,MULTIPLAN, 339.44,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23375,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23376,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23377,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23378,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,MULTIPLAN,MULTIPLAN, 435.45,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23379,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,MULTIPLAN,MULTIPLAN, 445.12,,OUTPCT LIMIT, 274.41,OTHER, 138.19, 484.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23380,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,MULTIPLAN,MULTIPLAN, 435.45,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23381,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23382,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23383,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23384,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,MULTIPLAN,MULTIPLAN, 680.40,,OUTPCT LIMIT, 402.07,OTHER, 138.19, 740.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23385,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,MULTIPLAN,MULTIPLAN, 668.03,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23386,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,MULTIPLAN,MULTIPLAN, 668.03,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23387,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23388,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23389,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23390,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,MULTIPLAN,MULTIPLAN, 244.78,,OUTPCT LIMIT, 153.37,OTHER, 86.34, 266.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23391,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23392,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,MULTIPLAN,MULTIPLAN, 410.11,,OUTPCT LIMIT, 243.07,OTHER, 86.34, 446.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23393,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,MULTIPLAN,MULTIPLAN, 400.44,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23394,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,MULTIPLAN,MULTIPLAN, 400.44,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23395,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23396,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23397,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23398,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,MULTIPLAN,MULTIPLAN, 77.40,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23399,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,MULTIPLAN,MULTIPLAN, 77.40,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23400,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,MULTIPLAN,MULTIPLAN, 154.80,,OUTPCT LIMIT, 116.89,OTHER, 73.96, 168.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23401,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23402,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23403,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23404,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,MULTIPLAN,MULTIPLAN, 342.89,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23405,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,MULTIPLAN,MULTIPLAN, 342.89,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23406,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,MULTIPLAN,MULTIPLAN, 354.60,,OUTPCT LIMIT, 225.30,OTHER, 138.19, 386.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23407,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23408,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23409,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23410,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,MULTIPLAN,MULTIPLAN, 387.90,,OUTPCT LIMIT, 243.37,OTHER, 138.19, 422.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23411,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,MULTIPLAN,MULTIPLAN, 375.73,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23412,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,MULTIPLAN,MULTIPLAN, 375.73,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23413,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23414,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23415,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23416,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,MULTIPLAN,MULTIPLAN, 305.96,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23417,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,MULTIPLAN,MULTIPLAN, 305.96,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23418,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23419,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23420,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,MULTIPLAN,MULTIPLAN, 423.23,,OUTPCT LIMIT, 250.19,OTHER, 86.34, 460.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23421,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,MULTIPLAN,MULTIPLAN, 413.38,,OUTPCT LIMIT, 244.84,OTHER, 86.34, 450.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23422,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,MULTIPLAN,MULTIPLAN, 413.56,,OUTPCT LIMIT, 244.94,OTHER, 86.34, 450.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23423,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23424,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23425,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23426,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,MULTIPLAN,MULTIPLAN, 209.70,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23427,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,MULTIPLAN,MULTIPLAN, 209.70,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23428,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,MULTIPLAN,MULTIPLAN, 209.70,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23429,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23430,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23431,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23432,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MULTIPLAN,MULTIPLAN, 280.02,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23433,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MULTIPLAN,MULTIPLAN, 280.02,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23434,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MULTIPLAN,MULTIPLAN, 280.02,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23435,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MULTIPLAN,MULTIPLAN, 280.02,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23436,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MULTIPLAN,MULTIPLAN, 280.02,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23437,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MULTIPLAN,MULTIPLAN, 280.02,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23438,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MULTIPLAN,MULTIPLAN, 280.02,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23439,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MULTIPLAN,MULTIPLAN, 280.02,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23440,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 179.26,OTHER, 86.34, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23441,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,MULTIPLAN,MULTIPLAN, 280.02,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23442,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,MULTIPLAN,MULTIPLAN, 280.02,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23443,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23444,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23445,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23446,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23447,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23448,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23449,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23450,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23451,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23452,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23453,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23454,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MULTIPLAN,MULTIPLAN, 2062.76,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23455,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MULTIPLAN,MULTIPLAN, 2062.76,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23456,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,MULTIPLAN,MULTIPLAN, 2062.76,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23457,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,MULTIPLAN,MULTIPLAN, 2074.50,,OUTPCT LIMIT, 1193.14,OTHER, 283.82, 2258.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23458,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MULTIPLAN,MULTIPLAN, 2062.76,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23459,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MULTIPLAN,MULTIPLAN, 2062.76,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23460,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MULTIPLAN,MULTIPLAN, 2062.76,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23461,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MULTIPLAN,MULTIPLAN, 2062.76,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23462,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MULTIPLAN,MULTIPLAN, 2062.76,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23463,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,MULTIPLAN,MULTIPLAN, 2062.76,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23464,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MULTIPLAN,MULTIPLAN, 2062.76,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23465,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MULTIPLAN,MULTIPLAN, 2062.76,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23466,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,MULTIPLAN,MULTIPLAN, 2062.76,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23467,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,MULTIPLAN,MULTIPLAN, 2062.76,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23468,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23469,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23470,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23471,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23472,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23473,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23474,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23475,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23476,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23477,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23478,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23479,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23480,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23481,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23482,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,MULTIPLAN,MULTIPLAN, 2455.20,,OUTPCT LIMIT, 1435.02,OTHER, 432.18, 2673.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23483,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,MULTIPLAN,MULTIPLAN, 2442.99,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23484,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,MULTIPLAN,MULTIPLAN, 2442.99,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23485,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23486,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23487,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23488,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,MULTIPLAN,MULTIPLAN, 1214.10,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23489,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,MULTIPLAN,MULTIPLAN, 1214.10,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23490,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,MULTIPLAN,MULTIPLAN, 1214.10,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23491,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23492,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23493,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23494,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,MULTIPLAN,MULTIPLAN, 1250.10,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23495,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,MULTIPLAN,MULTIPLAN, 1250.10,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23496,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23497,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23498,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MULTIPLAN,MULTIPLAN, 2663.05,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23499,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MULTIPLAN,MULTIPLAN, 2663.05,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23500,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MULTIPLAN,MULTIPLAN, 2663.05,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23501,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MULTIPLAN,MULTIPLAN, 2663.05,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23502,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,MULTIPLAN,MULTIPLAN, 2663.05,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23503,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,MULTIPLAN,MULTIPLAN, 2663.05,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23504,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23505,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23506,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23507,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23508,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23509,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23510,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,MULTIPLAN,MULTIPLAN, 3258.34,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23511,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,MULTIPLAN,MULTIPLAN, 3258.34,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23512,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23513,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23514,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MULTIPLAN,MULTIPLAN, 2838.36,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23515,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MULTIPLAN,MULTIPLAN, 2838.36,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23516,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,MULTIPLAN,MULTIPLAN, 2838.37,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23517,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,MULTIPLAN,MULTIPLAN, 2838.37,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23518,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MULTIPLAN,MULTIPLAN, 2838.36,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23519,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,MULTIPLAN,MULTIPLAN, 2838.36,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23520,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MULTIPLAN,MULTIPLAN, 2838.36,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23521,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,MULTIPLAN,MULTIPLAN, 2838.36,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23522,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,MULTIPLAN,MULTIPLAN, 2838.36,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23523,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,MULTIPLAN,MULTIPLAN, 2838.36,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23524,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23525,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23526,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23527,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23528,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23529,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23530,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23531,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23532,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23533,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23534,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,MULTIPLAN,MULTIPLAN, 4142.62,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23535,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,MULTIPLAN,MULTIPLAN, 4142.62,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23536,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MULTIPLAN,MULTIPLAN, 4142.62,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23537,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MULTIPLAN,MULTIPLAN, 4142.62,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23538,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,MULTIPLAN,MULTIPLAN, 4142.62,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23539,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23540,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23541,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23542,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23543,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23544,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MULTIPLAN,MULTIPLAN, 1800.00,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23545,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,MULTIPLAN,MULTIPLAN, 2070.00,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23546,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MULTIPLAN,MULTIPLAN, 2070.00,,OUTPCT LIMIT, 1474.10,OTHER, 989.00, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23547,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,MULTIPLAN,MULTIPLAN, 1647.00,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23548,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,MULTIPLAN,MULTIPLAN, 1647.00,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23549,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23550,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23551,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23552,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23553,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23554,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,MULTIPLAN,MULTIPLAN, 149.40,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23555,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,MULTIPLAN,MULTIPLAN, 149.40,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23556,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23557,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23558,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,MULTIPLAN,MULTIPLAN, 77.40,,OUTPCT LIMIT, 83.13,OTHER, 36.98, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23559,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 105.42,OTHER, 37.54, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23560,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,MULTIPLAN,MULTIPLAN, 533.63,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23561,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,MULTIPLAN,MULTIPLAN, 533.63,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23562,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23563,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23564,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,MULTIPLAN,MULTIPLAN, 2356.28,,OUTPCT LIMIT, 1346.03,OTHER, 283.82, 2565.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23565,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23566,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,MULTIPLAN,MULTIPLAN, 2656.46,,OUTPCT LIMIT, 1544.22,OTHER, 432.18, 2892.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23567,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23568,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,MULTIPLAN,MULTIPLAN, 2999.90,,OUTPCT LIMIT, 1743.20,OTHER, 485.27, 3266.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23569,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23570,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MULTIPLAN,MULTIPLAN, 5382.03,,OUTPCT LIMIT, 3113.75,OTHER, 813.20, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23571,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,MULTIPLAN,MULTIPLAN, 319.50,,OUTPCT LIMIT, 473.04,OTHER, 156.77, 813.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23572,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,MULTIPLAN,MULTIPLAN, 2995.94,,OUTPCT LIMIT, 1743.46,OTHER, 495.38, 3262.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23573,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23574,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,MULTIPLAN,MULTIPLAN, 4688.29,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23575,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,MULTIPLAN,MULTIPLAN, 4688.29,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23576,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23577,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23578,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MULTIPLAN,MULTIPLAN, 5382.03,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23579,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,MULTIPLAN,MULTIPLAN, 5382.03,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23580,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23581,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23582,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MULTIPLAN,MULTIPLAN, 6030.19,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23583,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MULTIPLAN,MULTIPLAN, 6030.19,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23584,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,MULTIPLAN,MULTIPLAN, 6030.19,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23585,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23586,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23587,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23588,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,MULTIPLAN,MULTIPLAN, 2891.03,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23589,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,MULTIPLAN,MULTIPLAN, 2891.03,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23590,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23591,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23592,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,MULTIPLAN,MULTIPLAN, 3043.97,,OUTPCT LIMIT, 1837.06,OTHER, 779.04, 3314.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23593,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23594,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,MULTIPLAN,MULTIPLAN, 2250.00,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23595,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,MULTIPLAN,MULTIPLAN, 3643.20,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23596,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23597,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23598,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23599,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MULTIPLAN,MULTIPLAN, 628.20,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23600,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MULTIPLAN,MULTIPLAN, 628.20,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23601,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,MULTIPLAN,MULTIPLAN, 628.20,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23602,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23603,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23604,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,MULTIPLAN,MULTIPLAN, 988.68,,OUTPCT LIMIT, 704.06,OTHER, 472.37, 1076.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23605,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 68.02,OTHER, 37.54, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23606,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,MULTIPLAN,MULTIPLAN, 347.76,,OUTPCT LIMIT, 248.14,OTHER, 166.15, 378.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23607,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 230.64,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23608,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,MULTIPLAN,MULTIPLAN, 682.72,,OUTPCT LIMIT, 429.88,OTHER, 249.71, 743.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23609,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 132.91,OTHER, 37.54, 249.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23610,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,MULTIPLAN,MULTIPLAN, 2539.06,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23611,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,MULTIPLAN,MULTIPLAN, 2539.06,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23612,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23613,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23614,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,MULTIPLAN,MULTIPLAN, 315.00,,OUTPCT LIMIT, 224.32,OTHER, 150.50, 343.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23615,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23616,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MULTIPLAN,MULTIPLAN, 648.44,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23617,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MULTIPLAN,MULTIPLAN, 648.44,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23618,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,MULTIPLAN,MULTIPLAN, 648.44,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23619,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23620,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23621,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23622,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,MULTIPLAN,MULTIPLAN, 488.32,,OUTPCT LIMIT, 286.59,OTHER, 90.89, 531.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23623,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23624,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,MULTIPLAN,MULTIPLAN, 460.20,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23625,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,MULTIPLAN,MULTIPLAN, 460.20,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23626,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,MULTIPLAN,MULTIPLAN, 460.20,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23627,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,MULTIPLAN,MULTIPLAN, 472.50,,OUTPCT LIMIT, 288.12,OTHER, 133.37, 514.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23628,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23629,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23630,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23631,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23632,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,MULTIPLAN,MULTIPLAN, 865.85,,OUTPCT LIMIT, 503.49,OTHER, 141.55, 942.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23633,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23634,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MULTIPLAN,MULTIPLAN, 790.74,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23635,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MULTIPLAN,MULTIPLAN, 790.74,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23636,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MULTIPLAN,MULTIPLAN, 790.74,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23637,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MULTIPLAN,MULTIPLAN, 790.74,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23638,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MULTIPLAN,MULTIPLAN, 790.74,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23639,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23640,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23641,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23642,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23643,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23644,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,MULTIPLAN,MULTIPLAN, 790.74,,OUTPCT LIMIT, 468.07,OTHER, 163.97, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23645,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 200.02,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23646,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MULTIPLAN,MULTIPLAN, 713.16,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23647,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MULTIPLAN,MULTIPLAN, 713.16,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23648,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MULTIPLAN,MULTIPLAN, 713.16,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23649,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,MULTIPLAN,MULTIPLAN, 713.16,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23650,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,MULTIPLAN,MULTIPLAN, 701.85,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23651,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23652,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23653,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23654,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23655,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23656,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,MULTIPLAN,MULTIPLAN, 701.85,,OUTPCT LIMIT, 414.50,OTHER, 141.55, 764.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23657,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23658,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,MULTIPLAN,MULTIPLAN, 337.50,,OUTPCT LIMIT, 214.87,OTHER, 133.37, 367.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23659,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 163.37,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23660,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,MULTIPLAN,MULTIPLAN, 691.21,,OUTPCT LIMIT, 408.73,OTHER, 141.55, 752.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23661,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23662,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,MULTIPLAN,MULTIPLAN, 873.34,,OUTPCT LIMIT, 507.55,OTHER, 141.55, 950.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23663,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23664,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,MULTIPLAN,MULTIPLAN, 1389.60,,OUTPCT LIMIT, 775.60,OTHER, 90.89, 1513.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23665,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23666,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,MULTIPLAN,MULTIPLAN, 477.00,,OUTPCT LIMIT, 290.56,OTHER, 133.37, 519.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23667,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23668,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,MULTIPLAN,MULTIPLAN, 711.56,,OUTPCT LIMIT, 419.77,OTHER, 141.55, 774.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23669,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23670,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MULTIPLAN,MULTIPLAN, 807.05,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23671,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MULTIPLAN,MULTIPLAN, 807.05,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23672,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,MULTIPLAN,MULTIPLAN, 807.05,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23673,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23674,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23675,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23676,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,MULTIPLAN,MULTIPLAN, 563.18,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23677,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,MULTIPLAN,MULTIPLAN, 544.43,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23678,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23679,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23680,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,MULTIPLAN,MULTIPLAN, 690.73,,OUTPCT LIMIT, 408.48,OTHER, 141.55, 752.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23681,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23682,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,MULTIPLAN,MULTIPLAN, 1440.00,,OUTPCT LIMIT, 813.95,OTHER, 137.10, 1568.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23683,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,MULTIPLAN,MULTIPLAN, 910.48,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23684,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,MULTIPLAN,MULTIPLAN, 910.48,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23685,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23686,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23687,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23688,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MULTIPLAN,MULTIPLAN, 323.06,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23689,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,MULTIPLAN,MULTIPLAN, 495.00,,OUTPCT LIMIT, 300.33,OTHER, 133.37, 539.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23690,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MULTIPLAN,MULTIPLAN, 323.06,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23691,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MULTIPLAN,MULTIPLAN, 323.06,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23692,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MULTIPLAN,MULTIPLAN, 323.06,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23693,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MULTIPLAN,MULTIPLAN, 323.06,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23694,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MULTIPLAN,MULTIPLAN, 323.06,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23695,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,MULTIPLAN,MULTIPLAN, 323.06,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23696,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,MULTIPLAN,MULTIPLAN, 323.06,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23697,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23698,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23699,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23700,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23701,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23702,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23703,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23704,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23705,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23706,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,MULTIPLAN,MULTIPLAN, 598.40,,OUTPCT LIMIT, 426.14,OTHER, 285.90, 651.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23707,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23708,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MULTIPLAN,MULTIPLAN, 382.13,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23709,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MULTIPLAN,MULTIPLAN, 382.13,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23710,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,MULTIPLAN,MULTIPLAN, 382.13,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23711,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,MULTIPLAN,MULTIPLAN, 321.30,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23712,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23713,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,MULTIPLAN,MULTIPLAN, 321.30,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23714,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,MULTIPLAN,MULTIPLAN, 321.30,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23715,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,MULTIPLAN,MULTIPLAN, 261.90,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23716,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,MULTIPLAN,MULTIPLAN, 261.90,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23717,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,MULTIPLAN,MULTIPLAN, 127.80,,OUTPCT LIMIT, 91.01,OTHER, 61.06, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23718,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,MULTIPLAN,MULTIPLAN, 166.50,,OUTPCT LIMIT, 78.82,OTHER, 21.15, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23719,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MULTIPLAN,MULTIPLAN, 261.90,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23720,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MULTIPLAN,MULTIPLAN, 261.90,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23721,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MULTIPLAN,MULTIPLAN, 261.90,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23722,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MULTIPLAN,MULTIPLAN, 261.90,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23723,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23724,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23725,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23726,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23727,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,MULTIPLAN,MULTIPLAN, 441.00,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23728,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,MULTIPLAN,MULTIPLAN, 368.10,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23729,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,MULTIPLAN,MULTIPLAN, 441.00,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23730,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23731,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23732,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MULTIPLAN,MULTIPLAN, 261.90,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23733,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MULTIPLAN,MULTIPLAN, 261.90,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23734,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,MULTIPLAN,MULTIPLAN, 261.90,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23735,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,MULTIPLAN,MULTIPLAN, 261.90,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23736,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,MULTIPLAN,MULTIPLAN, 540.00,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23737,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,MULTIPLAN,MULTIPLAN, 373.50,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23738,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,MULTIPLAN,MULTIPLAN, 373.50,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23739,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23740,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23741,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23742,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23743,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23744,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23745,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23746,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,MULTIPLAN,MULTIPLAN, 153.90,,OUTPCT LIMIT, 116.40,OTHER, 73.53, 167.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23747,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,MULTIPLAN,MULTIPLAN, 37.80,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23748,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,MULTIPLAN,MULTIPLAN, 661.35,,OUTPCT LIMIT, 414.07,OTHER, 232.03, 720.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23749,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,MULTIPLAN,MULTIPLAN, 176.40,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23750,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,MULTIPLAN,MULTIPLAN, 315.90,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23751,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,MULTIPLAN,MULTIPLAN, 37.80,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23752,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,MULTIPLAN,MULTIPLAN, 37.80,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23753,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,MULTIPLAN,MULTIPLAN, 266.40,,OUTPCT LIMIT, 154.63,OTHER, 42.36, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23754,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,MULTIPLAN,MULTIPLAN, 315.90,,OUTPCT LIMIT, 204.30,OTHER, 138.19, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23755,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,MULTIPLAN,MULTIPLAN, 37.80,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23756,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,MULTIPLAN,MULTIPLAN, 1149.15,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23757,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,MULTIPLAN,MULTIPLAN, 1149.15,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23758,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23759,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23760,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,MULTIPLAN,MULTIPLAN, 893.30,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23761,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,MULTIPLAN,MULTIPLAN, 893.30,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23762,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23763,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23764,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,MULTIPLAN,MULTIPLAN, 1256.32,,OUTPCT LIMIT, 757.92,OTHER, 320.35, 1367.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23765,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 230.15,OTHER, 99.36, 320.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23766,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,MULTIPLAN,MULTIPLAN, 1516.85,,OUTPCT LIMIT, 899.81,OTHER, 322.62, 1651.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23767,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 230.96,OTHER, 99.36, 322.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23768,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,MULTIPLAN,MULTIPLAN, 1773.00,,OUTPCT LIMIT, 1092.65,OTHER, 548.80, 1930.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23769,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 311.74,OTHER, 99.36, 548.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23770,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,MULTIPLAN,MULTIPLAN, 1406.82,,OUTPCT LIMIT, 864.03,OTHER, 423.08, 1531.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23771,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23772,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,MULTIPLAN,MULTIPLAN, 450.00,,OUTPCT LIMIT, 344.89,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23773,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23774,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,MULTIPLAN,MULTIPLAN, 1350.00,,OUTPCT LIMIT, 830.31,OTHER, 410.92, 1470.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23775,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23776,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,MULTIPLAN,MULTIPLAN, 1854.00,,OUTPCT LIMIT, 1103.77,OTHER, 410.92, 2018.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23777,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23778,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,MULTIPLAN,MULTIPLAN, 1890.00,,OUTPCT LIMIT, 1111.16,OTHER, 359.95, 2058.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23779,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23780,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,MULTIPLAN,MULTIPLAN, 992.25,,OUTPCT LIMIT, 624.07,OTHER, 359.95, 1080.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23781,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23782,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,MULTIPLAN,MULTIPLAN, 1081.20,,OUTPCT LIMIT, 672.34,OTHER, 360.01, 1177.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23783,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23784,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,MULTIPLAN,MULTIPLAN, 873.00,,OUTPCT LIMIT, 559.38,OTHER, 360.01, 950.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23785,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23786,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,MULTIPLAN,MULTIPLAN, 2105.42,,OUTPCT LIMIT, 1228.06,OTHER, 360.01, 2292.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23787,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23788,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,MULTIPLAN,MULTIPLAN, 2227.06,,OUTPCT LIMIT, 1294.05,OTHER, 360.01, 2425.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23789,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23790,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,MULTIPLAN,MULTIPLAN, 985.50,,OUTPCT LIMIT, 701.80,OTHER, 470.85, 1073.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23791,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 180.04,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23792,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,MULTIPLAN,MULTIPLAN, 1623.15,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23793,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,MULTIPLAN,MULTIPLAN, 1623.15,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23794,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23795,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23796,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,MULTIPLAN,MULTIPLAN, 3684.85,,OUTPCT LIMIT, 2267.81,OTHER, 1127.76, 4012.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23797,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23798,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,MULTIPLAN,MULTIPLAN, 1306.89,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23799,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,MULTIPLAN,MULTIPLAN, 1306.89,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23800,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23801,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23802,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,MULTIPLAN,MULTIPLAN, 1047.38,,OUTPCT LIMIT, 635.79,OTHER, 283.54, 1140.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23803,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 217.00,OTHER, 99.36, 283.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23804,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,MULTIPLAN,MULTIPLAN, 1681.95,,OUTPCT LIMIT, 984.09,OTHER, 300.36, 1831.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23805,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 223.01,OTHER, 99.36, 300.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23806,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,MULTIPLAN,MULTIPLAN, 1740.89,,OUTPCT LIMIT, 1050.06,OTHER, 443.12, 1895.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23807,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 274.00,OTHER, 99.36, 443.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23808,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,MULTIPLAN,MULTIPLAN, 936.00,,OUTPCT LIMIT, 684.67,OTHER, 447.20, 1019.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23809,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,MULTIPLAN,MULTIPLAN, 202.50,,OUTPCT LIMIT, 380.97,OTHER, 99.36, 742.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23810,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,MULTIPLAN,MULTIPLAN, 4287.60,,OUTPCT LIMIT, 2685.69,OTHER, 1509.32, 4668.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23811,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,MULTIPLAN,MULTIPLAN, 360.00,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23812,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,MULTIPLAN,MULTIPLAN, 4440.60,,OUTPCT LIMIT, 2768.70,OTHER, 1509.32, 4835.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23813,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,MULTIPLAN,MULTIPLAN, 360.00,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23814,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,MULTIPLAN,MULTIPLAN, 54.53,,OUTPCT LIMIT, 34.30,OTHER, 19.78, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23815,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,MULTIPLAN,MULTIPLAN, 54.53,,OUTPCT LIMIT, 32.49,OTHER, 12.18, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23816,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,MULTIPLAN,MULTIPLAN, 559.80,,OUTPCT LIMIT, 398.65,OTHER, 267.46, 609.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23817,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,MULTIPLAN,MULTIPLAN, 125.87,,OUTPCT LIMIT, 70.69,OTHER, 10.09, 137.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23818,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,MULTIPLAN,MULTIPLAN, 218.48,,OUTPCT LIMIT, 122.16,OTHER, 15.20, 237.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23819,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,MULTIPLAN,MULTIPLAN, 171.42,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23820,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,MULTIPLAN,MULTIPLAN, 171.42,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23821,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,MULTIPLAN,MULTIPLAN, 148.50,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23822,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,MULTIPLAN,MULTIPLAN, 148.50,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23823,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,MULTIPLAN,MULTIPLAN, 257.15,,OUTPCT LIMIT, 155.85,OTHER, 68.59, 280.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23824,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,MULTIPLAN,MULTIPLAN, 140.41,,OUTPCT LIMIT, 78.98,OTHER, 11.76, 152.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23825,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,MULTIPLAN,MULTIPLAN, 117.90,,OUTPCT LIMIT, 69.30,OTHER, 22.37, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23826,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,MULTIPLAN,MULTIPLAN, 402.30,,OUTPCT LIMIT, 229.30,OTHER, 46.28, 438.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23827,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,MULTIPLAN,MULTIPLAN, 158.63,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23828,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,MULTIPLAN,MULTIPLAN, 150.84,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23829,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,MULTIPLAN,MULTIPLAN, 90.01,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23830,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,MULTIPLAN,MULTIPLAN, 90.01,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23831,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,MULTIPLAN,MULTIPLAN, 139.20,,OUTPCT LIMIT, 80.17,OTHER, 19.50, 151.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23832,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,MULTIPLAN,MULTIPLAN, 86.96,,OUTPCT LIMIT, 54.61,OTHER, 31.20, 94.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23833,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,MULTIPLAN,MULTIPLAN, 139.12,,OUTPCT LIMIT, 80.03,OTHER, 19.08, 151.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23834,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,MULTIPLAN,MULTIPLAN, 137.55,,OUTPCT LIMIT, 79.17,OTHER, 19.08, 149.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23835,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,MULTIPLAN,MULTIPLAN, 113.69,,OUTPCT LIMIT, 63.95,OTHER, 9.52, 123.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23836,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,MULTIPLAN,MULTIPLAN, 42.30,,OUTPCT LIMIT, 28.28,OTHER, 20.21, 46.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23837,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,MULTIPLAN,MULTIPLAN, 145.87,,OUTPCT LIMIT, 83.69,OTHER, 19.08, 158.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23838,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,MULTIPLAN,MULTIPLAN, 88.88,,OUTPCT LIMIT, 53.47,OTHER, 22.03, 96.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23839,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,MULTIPLAN,MULTIPLAN, 138.73,,OUTPCT LIMIT, 79.81,OTHER, 19.08, 151.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23840,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,MULTIPLAN,MULTIPLAN, 73.60,,OUTPCT LIMIT, 44.64,OTHER, 19.78, 80.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23841,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,MULTIPLAN,MULTIPLAN, 260.25,,OUTPCT LIMIT, 145.91,OTHER, 19.78, 283.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23842,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,MULTIPLAN,MULTIPLAN, 110.43,,OUTPCT LIMIT, 64.76,OTHER, 20.36, 120.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23843,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,MULTIPLAN,MULTIPLAN, 216.11,,OUTPCT LIMIT, 121.34,OTHER, 17.16, 235.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23844,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,MULTIPLAN,MULTIPLAN, 147.65,,OUTPCT LIMIT, 84.76,OTHER, 19.50, 160.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23845,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,MULTIPLAN,MULTIPLAN, 233.97,,OUTPCT LIMIT, 134.69,OTHER, 32.53, 254.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23846,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,MULTIPLAN,MULTIPLAN, 155.77,,OUTPCT LIMIT, 90.91,OTHER, 26.84, 169.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23847,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,MULTIPLAN,MULTIPLAN, 171.31,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23848,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,MULTIPLAN,MULTIPLAN, 22.50,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23849,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,MULTIPLAN,MULTIPLAN, 36.00,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23850,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,MULTIPLAN,MULTIPLAN, 36.00,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23851,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,MULTIPLAN,MULTIPLAN, 235.69,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23852,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,MULTIPLAN,MULTIPLAN, 265.50,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23853,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,MULTIPLAN,MULTIPLAN, 152.10,,OUTPCT LIMIT, 108.31,OTHER, 72.67, 165.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23854,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,MULTIPLAN,MULTIPLAN, 135.00,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23855,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,MULTIPLAN,MULTIPLAN, 68.40,,OUTPCT LIMIT, 48.71,OTHER, 32.68, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23856,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,MULTIPLAN,MULTIPLAN, 252.69,,OUTPCT LIMIT, 179.95,OTHER, 120.73, 275.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23857,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,MULTIPLAN,MULTIPLAN, 160.97,,OUTPCT LIMIT, 114.63,OTHER, 76.91, 175.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23858,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,MULTIPLAN,MULTIPLAN, 36.75,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23859,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,MULTIPLAN,MULTIPLAN, 67.50,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23860,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,MULTIPLAN,MULTIPLAN, 36.75,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23861,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,MULTIPLAN,MULTIPLAN, 36.75,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23862,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,MULTIPLAN,MULTIPLAN, 126.90,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23863,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,MULTIPLAN,MULTIPLAN, 95.30,,OUTPCT LIMIT, 67.87,OTHER, 45.53, 103.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23864,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,MULTIPLAN,MULTIPLAN, 143.10,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23865,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,MULTIPLAN,MULTIPLAN, 143.10,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23866,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,MULTIPLAN,MULTIPLAN, 143.10,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23867,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,MULTIPLAN,MULTIPLAN, 121.50,,OUTPCT LIMIT, 86.52,OTHER, 58.05, 132.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23868,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,MULTIPLAN,MULTIPLAN, 77.40,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23869,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,MULTIPLAN,MULTIPLAN, 261.90,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23870,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,MULTIPLAN,MULTIPLAN, 62.29,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23871,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,MULTIPLAN,MULTIPLAN, 62.29,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23872,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,MULTIPLAN,MULTIPLAN, 62.29,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23873,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,MULTIPLAN,MULTIPLAN, 37.16,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23874,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,MULTIPLAN,MULTIPLAN, 37.16,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23875,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,MULTIPLAN,MULTIPLAN, 37.16,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23876,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,MULTIPLAN,MULTIPLAN, 11.70,,OUTPCT LIMIT, 7.12,OTHER, 3.24, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23877,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,MULTIPLAN,MULTIPLAN, 13.50,,OUTPCT LIMIT, 8.07,OTHER, 3.12, 14.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23878,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,MULTIPLAN,MULTIPLAN, 56.97,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23879,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,MULTIPLAN,MULTIPLAN, 56.97,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23880,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,MULTIPLAN,MULTIPLAN, 134.10,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23881,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,MULTIPLAN,MULTIPLAN, 134.10,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23882,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,MULTIPLAN,MULTIPLAN, 221.98,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23883,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,MULTIPLAN,MULTIPLAN, 221.98,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23884,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,MULTIPLAN,MULTIPLAN, 442.80,,OUTPCT LIMIT, 262.66,OTHER, 94.12, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23885,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,MULTIPLAN,MULTIPLAN, 732.73,,OUTPCT LIMIT, 428.98,OTHER, 131.99, 797.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23886,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,MULTIPLAN,MULTIPLAN, 182.11,,OUTPCT LIMIT, 129.68,OTHER, 87.01, 198.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23887,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,MULTIPLAN,MULTIPLAN, 343.80,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23888,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,MULTIPLAN,MULTIPLAN, 343.80,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23889,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,MULTIPLAN,MULTIPLAN, 95.10,,OUTPCT LIMIT, 53.15,OTHER, 6.50, 103.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23890,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,MULTIPLAN,MULTIPLAN, 66.55,,OUTPCT LIMIT, 38.90,OTHER, 11.76, 72.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23891,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,MULTIPLAN,MULTIPLAN, 246.22,,OUTPCT LIMIT, 146.83,OTHER, 55.61, 268.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23892,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,MULTIPLAN,MULTIPLAN, 33.98,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23893,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,MULTIPLAN,MULTIPLAN, 33.98,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23894,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,MULTIPLAN,MULTIPLAN, 48.38,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23895,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,MULTIPLAN,MULTIPLAN, 48.38,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23896,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,MULTIPLAN,MULTIPLAN, 108.00,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23897,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,MULTIPLAN,MULTIPLAN, 108.00,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23898,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,MULTIPLAN,MULTIPLAN, 87.63,,OUTPCT LIMIT, 50.88,OTHER, 13.98, 95.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23899,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,MULTIPLAN,MULTIPLAN, 122.48,,OUTPCT LIMIT, 71.06,OTHER, 19.36, 133.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23900,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,MULTIPLAN,MULTIPLAN, 193.35,,OUTPCT LIMIT, 109.86,OTHER, 20.82, 210.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23901,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,MULTIPLAN,MULTIPLAN, 137.15,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23902,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,MULTIPLAN,MULTIPLAN, 137.15,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23903,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,MULTIPLAN,MULTIPLAN, 107.10,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23904,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,MULTIPLAN,MULTIPLAN, 107.10,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23905,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,MULTIPLAN,MULTIPLAN, 89.51,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23906,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,MULTIPLAN,MULTIPLAN, 89.51,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23907,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,MULTIPLAN,MULTIPLAN, 166.50,,OUTPCT LIMIT, 100.38,OTHER, 42.16, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23908,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,MULTIPLAN,MULTIPLAN, 204.38,,OUTPCT LIMIT, 121.92,OTHER, 46.34, 222.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23909,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,MULTIPLAN,MULTIPLAN, 79.20,,OUTPCT LIMIT, 50.20,OTHER, 30.37, 86.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23910,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,MULTIPLAN,MULTIPLAN, 202.39,,OUTPCT LIMIT, 116.31,OTHER, 27.31, 220.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23911,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,MULTIPLAN,MULTIPLAN, 85.50,,OUTPCT LIMIT, 49.78,OTHER, 14.24, 93.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23912,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,MULTIPLAN,MULTIPLAN, 106.70,,OUTPCT LIMIT, 63.44,OTHER, 23.30, 116.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23913,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,MULTIPLAN,MULTIPLAN, 63.85,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23914,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,MULTIPLAN,MULTIPLAN, 63.85,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23915,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,MULTIPLAN,MULTIPLAN, 57.78,,OUTPCT LIMIT, 33.07,OTHER, 7.22, 62.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23916,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,MULTIPLAN,MULTIPLAN, 32.85,,OUTPCT LIMIT, 19.33,OTHER, 6.31, 35.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23917,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,MULTIPLAN,MULTIPLAN, 58.65,,OUTPCT LIMIT, 33.34,OTHER, 6.38, 63.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23918,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 56.73,OTHER, 22.92, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23919,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,MULTIPLAN,MULTIPLAN, 210.10,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23920,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,MULTIPLAN,MULTIPLAN, 224.10,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23921,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,MULTIPLAN,MULTIPLAN, 210.10,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23922,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,MULTIPLAN,MULTIPLAN, 210.98,,OUTPCT LIMIT, 123.66,OTHER, 38.58, 229.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23923,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,MULTIPLAN,MULTIPLAN, 59.55,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23924,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,MULTIPLAN,MULTIPLAN, 59.55,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23925,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,MULTIPLAN,MULTIPLAN, 59.55,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23926,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,MULTIPLAN,MULTIPLAN, 118.97,,OUTPCT LIMIT, 69.24,OTHER, 19.70, 129.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23927,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,MULTIPLAN,MULTIPLAN, 88.28,,OUTPCT LIMIT, 49.97,OTHER, 8.69, 96.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23928,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,MULTIPLAN,MULTIPLAN, 73.80,,OUTPCT LIMIT, 44.47,OTHER, 18.58, 80.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23929,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,MULTIPLAN,MULTIPLAN, 112.28,,OUTPCT LIMIT, 65.14,OTHER, 17.74, 122.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23930,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,MULTIPLAN,MULTIPLAN, 148.82,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23931,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,MULTIPLAN,MULTIPLAN, 148.82,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23932,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,MULTIPLAN,MULTIPLAN, 98.10,,OUTPCT LIMIT, 59.01,OTHER, 24.29, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23933,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,MULTIPLAN,MULTIPLAN, 218.79,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23934,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,MULTIPLAN,MULTIPLAN, 220.88,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23935,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,MULTIPLAN,MULTIPLAN, 97.26,,OUTPCT LIMIT, 56.46,OTHER, 15.47, 105.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23936,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,MULTIPLAN,MULTIPLAN, 21.60,,OUTPCT LIMIT, 13.69,OTHER, 8.28, 23.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23937,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,MULTIPLAN,MULTIPLAN, 128.02,,OUTPCT LIMIT, 73.71,OTHER, 17.87, 139.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23938,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,MULTIPLAN,MULTIPLAN, 151.14,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23939,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,MULTIPLAN,MULTIPLAN, 151.14,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23940,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,MULTIPLAN,MULTIPLAN, 111.92,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23941,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,MULTIPLAN,MULTIPLAN, 111.92,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23942,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,MULTIPLAN,MULTIPLAN, 335.30,,OUTPCT LIMIT, 190.19,OTHER, 34.69, 365.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23943,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,MULTIPLAN,MULTIPLAN, 379.22,,OUTPCT LIMIT, 214.01,OTHER, 34.69, 412.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23944,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,MULTIPLAN,MULTIPLAN, 83.41,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23945,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,MULTIPLAN,MULTIPLAN, 83.41,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23946,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,MULTIPLAN,MULTIPLAN, 68.40,,OUTPCT LIMIT, 41.70,OTHER, 19.28, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23947,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,MULTIPLAN,MULTIPLAN, 102.78,,OUTPCT LIMIT, 59.73,OTHER, 16.63, 111.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23948,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,MULTIPLAN,MULTIPLAN, 55.05,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23949,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,MULTIPLAN,MULTIPLAN, 55.05,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23950,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,MULTIPLAN,MULTIPLAN, 55.05,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23951,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,MULTIPLAN,MULTIPLAN, 68.81,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23952,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,MULTIPLAN,MULTIPLAN, 68.81,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23953,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,MULTIPLAN,MULTIPLAN, 166.29,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23954,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,MULTIPLAN,MULTIPLAN, 166.29,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23955,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,MULTIPLAN,MULTIPLAN, 75.60,,OUTPCT LIMIT, 45.06,OTHER, 16.97, 82.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23956,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,MULTIPLAN,MULTIPLAN, 136.38,,OUTPCT LIMIT, 76.21,OTHER, 9.31, 148.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23957,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,MULTIPLAN,MULTIPLAN, 123.60,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23958,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,MULTIPLAN,MULTIPLAN, 123.60,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23959,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,MULTIPLAN,MULTIPLAN, 127.20,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23960,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,MULTIPLAN,MULTIPLAN, 127.20,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23961,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,MULTIPLAN,MULTIPLAN, 218.88,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23962,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,MULTIPLAN,MULTIPLAN, 218.88,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23963,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,MULTIPLAN,MULTIPLAN, 161.14,,OUTPCT LIMIT, 93.87,OTHER, 27.06, 175.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23964,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,MULTIPLAN,MULTIPLAN, 232.06,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23965,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,MULTIPLAN,MULTIPLAN, 232.06,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23966,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,MULTIPLAN,MULTIPLAN, 134.10,,OUTPCT LIMIT, 83.83,OTHER, 46.51, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23967,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,MULTIPLAN,MULTIPLAN, 120.60,,OUTPCT LIMIT, 73.72,OTHER, 34.82, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23968,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,MULTIPLAN,MULTIPLAN, 123.30,,OUTPCT LIMIT, 75.45,OTHER, 35.93, 134.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23969,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,MULTIPLAN,MULTIPLAN, 209.48,,OUTPCT LIMIT, 121.64,OTHER, 33.53, 228.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23970,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,MULTIPLAN,MULTIPLAN, 124.25,,OUTPCT LIMIT, 69.17,OTHER, 7.34, 135.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23971,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,MULTIPLAN,MULTIPLAN, 219.16,,OUTPCT LIMIT, 124.67,OTHER, 24.19, 238.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23972,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,MULTIPLAN,MULTIPLAN, 132.30,,OUTPCT LIMIT, 76.46,OTHER, 19.63, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23973,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,MULTIPLAN,MULTIPLAN, 122.45,,OUTPCT LIMIT, 71.48,OTHER, 21.17, 133.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23974,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,MULTIPLAN,MULTIPLAN, 381.38,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23975,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,MULTIPLAN,MULTIPLAN, 139.51,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23976,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,MULTIPLAN,MULTIPLAN, 95.18,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23977,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,MULTIPLAN,MULTIPLAN, 95.18,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23978,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,MULTIPLAN,MULTIPLAN, 95.18,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23979,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,MULTIPLAN,MULTIPLAN, 109.32,,OUTPCT LIMIT, 64.96,OTHER, 23.70, 119.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23980,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,MULTIPLAN,MULTIPLAN, 59.40,,OUTPCT LIMIT, 34.98,OTHER, 11.54, 64.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23981,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,MULTIPLAN,MULTIPLAN, 358.63,,OUTPCT LIMIT, 203.52,OTHER, 37.54, 390.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23982,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,MULTIPLAN,MULTIPLAN, 102.60,,OUTPCT LIMIT, 61.71,OTHER, 25.39, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23983,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,MULTIPLAN,MULTIPLAN, 44.78,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23984,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,MULTIPLAN,MULTIPLAN, 44.78,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23985,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,MULTIPLAN,MULTIPLAN, 44.78,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23986,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,MULTIPLAN,MULTIPLAN, 49.71,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23987,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,MULTIPLAN,MULTIPLAN, 49.71,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23988,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,MULTIPLAN,MULTIPLAN, 49.71,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23989,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,MULTIPLAN,MULTIPLAN, 23.58,,OUTPCT LIMIT, 14.14,OTHER, 5.66, 25.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23990,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,MULTIPLAN,MULTIPLAN, 115.80,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23991,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,MULTIPLAN,MULTIPLAN, 115.80,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23992,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,MULTIPLAN,MULTIPLAN, 100.61,,OUTPCT LIMIT, 57.91,OTHER, 13.97, 109.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23993,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,MULTIPLAN,MULTIPLAN, 64.65,,OUTPCT LIMIT, 37.55,OTHER, 10.37, 70.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23994,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,MULTIPLAN,MULTIPLAN, 162.86,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23995,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,MULTIPLAN,MULTIPLAN, 162.86,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23996,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,MULTIPLAN,MULTIPLAN, 162.50,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23997,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,MULTIPLAN,MULTIPLAN, 162.50,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23998,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,MULTIPLAN,MULTIPLAN, 115.62,,OUTPCT LIMIT, 67.05,OTHER, 18.12, 125.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 23999,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,MULTIPLAN,MULTIPLAN, 124.20,,OUTPCT LIMIT, 74.92,OTHER, 31.62, 135.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24000,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,MULTIPLAN,MULTIPLAN, 82.89,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24001,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,MULTIPLAN,MULTIPLAN, 82.89,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24002,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,MULTIPLAN,MULTIPLAN, 82.89,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24003,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,MULTIPLAN,MULTIPLAN, 172.67,,OUTPCT LIMIT, 99.83,OTHER, 25.80, 188.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24004,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,MULTIPLAN,MULTIPLAN, 270.90,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24005,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,MULTIPLAN,MULTIPLAN, 238.84,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24006,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,MULTIPLAN,MULTIPLAN, 238.84,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24007,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,MULTIPLAN,MULTIPLAN, 238.84,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24008,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,MULTIPLAN,MULTIPLAN, 238.84,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24009,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,MULTIPLAN,MULTIPLAN, 238.84,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24010,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,MULTIPLAN,MULTIPLAN, 266.95,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24011,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,MULTIPLAN,MULTIPLAN, 161.15,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24012,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,MULTIPLAN,MULTIPLAN, 248.48,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24013,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,MULTIPLAN,MULTIPLAN, 38.70,,OUTPCT LIMIT, 25.93,OTHER, 18.49, 42.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24014,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,MULTIPLAN,MULTIPLAN, 120.02,,OUTPCT LIMIT, 69.04,OTHER, 16.46, 130.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24015,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,MULTIPLAN,MULTIPLAN, 76.79,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24016,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,MULTIPLAN,MULTIPLAN, 76.79,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24017,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,MULTIPLAN,MULTIPLAN, 76.79,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24018,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,MULTIPLAN,MULTIPLAN, 93.96,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24019,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,MULTIPLAN,MULTIPLAN, 93.96,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24020,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,MULTIPLAN,MULTIPLAN, 93.96,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24021,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,MULTIPLAN,MULTIPLAN, 93.96,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24022,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,MULTIPLAN,MULTIPLAN, 121.77,,OUTPCT LIMIT, 70.04,OTHER, 16.66, 132.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24023,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,MULTIPLAN,MULTIPLAN, 77.81,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24024,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,MULTIPLAN,MULTIPLAN, 102.53,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24025,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,MULTIPLAN,MULTIPLAN, 149.40,,OUTPCT LIMIT, 85.45,OTHER, 18.42, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24026,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,MULTIPLAN,MULTIPLAN, 114.30,,OUTPCT LIMIT, 68.77,OTHER, 28.37, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24027,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,MULTIPLAN,MULTIPLAN, 93.29,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24028,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,MULTIPLAN,MULTIPLAN, 93.29,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24029,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,MULTIPLAN,MULTIPLAN, 107.11,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24030,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,MULTIPLAN,MULTIPLAN, 107.11,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24031,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,MULTIPLAN,MULTIPLAN, 245.45,,OUTPCT LIMIT, 149.05,OTHER, 66.68, 267.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24032,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,MULTIPLAN,MULTIPLAN, 58.50,,OUTPCT LIMIT, 43.46,OTHER, 27.95, 63.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24033,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,MULTIPLAN,MULTIPLAN, 72.63,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24034,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,MULTIPLAN,MULTIPLAN, 72.63,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24035,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,MULTIPLAN,MULTIPLAN, 70.67,,OUTPCT LIMIT, 40.64,OTHER, 9.65, 76.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24036,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,MULTIPLAN,MULTIPLAN, 360.82,,OUTPCT LIMIT, 204.04,OTHER, 34.72, 392.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24037,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,MULTIPLAN,MULTIPLAN, 95.69,,OUTPCT LIMIT, 57.49,OTHER, 23.41, 104.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24038,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,MULTIPLAN,MULTIPLAN, 283.38,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24039,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,MULTIPLAN,MULTIPLAN, 283.38,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24040,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,MULTIPLAN,MULTIPLAN, 150.00,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24041,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,MULTIPLAN,MULTIPLAN, 109.37,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24042,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,MULTIPLAN,MULTIPLAN, 197.10,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24043,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,MULTIPLAN,MULTIPLAN, 197.10,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24044,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,MULTIPLAN,MULTIPLAN, 191.10,,OUTPCT LIMIT, 110.95,OTHER, 30.54, 208.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24045,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,MULTIPLAN,MULTIPLAN, 95.66,,OUTPCT LIMIT, 54.17,OTHER, 9.52, 104.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24046,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,MULTIPLAN,MULTIPLAN, 77.62,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24047,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,MULTIPLAN,MULTIPLAN, 77.62,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24048,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,MULTIPLAN,MULTIPLAN, 149.64,,OUTPCT LIMIT, 86.15,OTHER, 20.81, 162.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24049,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,MULTIPLAN,MULTIPLAN, 244.85,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24050,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,MULTIPLAN,MULTIPLAN, 244.85,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24051,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,MULTIPLAN,MULTIPLAN, 68.40,,OUTPCT LIMIT, 43.75,OTHER, 27.89, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24052,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,MULTIPLAN,MULTIPLAN, 331.53,,OUTPCT LIMIT, 186.61,OTHER, 28.27, 361.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24053,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,MULTIPLAN,MULTIPLAN, 77.40,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24054,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,MULTIPLAN,MULTIPLAN, 85.14,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24055,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,MULTIPLAN,MULTIPLAN, 61.87,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24056,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,MULTIPLAN,MULTIPLAN, 61.87,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24057,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,MULTIPLAN,MULTIPLAN, 50.20,,OUTPCT LIMIT, 28.87,OTHER, 6.85, 54.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24058,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,MULTIPLAN,MULTIPLAN, 22.50,,OUTPCT LIMIT, 13.83,OTHER, 6.82, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24059,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,MULTIPLAN,MULTIPLAN, 74.75,,OUTPCT LIMIT, 45.56,OTHER, 21.01, 81.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24060,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,MULTIPLAN,MULTIPLAN, 157.72,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24061,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,MULTIPLAN,MULTIPLAN, 157.72,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24062,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,MULTIPLAN,MULTIPLAN, 172.26,,OUTPCT LIMIT, 102.79,OTHER, 39.19, 187.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24063,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,MULTIPLAN,MULTIPLAN, 166.84,,OUTPCT LIMIT, 97.17,OTHER, 27.91, 181.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24064,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,MULTIPLAN,MULTIPLAN, 148.78,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24065,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,MULTIPLAN,MULTIPLAN, 160.51,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24066,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,MULTIPLAN,MULTIPLAN, 160.51,,OUTPCT LIMIT, 93.39,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24067,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,MULTIPLAN,MULTIPLAN, 43.13,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24068,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,MULTIPLAN,MULTIPLAN, 43.13,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24069,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,MULTIPLAN,MULTIPLAN, 104.28,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24070,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,MULTIPLAN,MULTIPLAN, 104.28,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24071,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,MULTIPLAN,MULTIPLAN, 104.28,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24072,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,MULTIPLAN,MULTIPLAN, 73.62,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24073,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,MULTIPLAN,MULTIPLAN, 73.62,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24074,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,MULTIPLAN,MULTIPLAN, 76.88,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24075,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,MULTIPLAN,MULTIPLAN, 358.28,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24076,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,MULTIPLAN,MULTIPLAN, 159.17,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24077,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,MULTIPLAN,MULTIPLAN, 137.27,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24078,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,MULTIPLAN,MULTIPLAN, 362.13,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24079,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,MULTIPLAN,MULTIPLAN, 234.43,,OUTPCT LIMIT, 136.35,OTHER, 38.44, 255.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24080,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,MULTIPLAN,MULTIPLAN, 172.58,,OUTPCT LIMIT, 103.27,OTHER, 40.46, 187.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24081,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,MULTIPLAN,MULTIPLAN, 127.80,,OUTPCT LIMIT, 76.88,OTHER, 31.67, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24082,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,MULTIPLAN,MULTIPLAN, 316.80,,OUTPCT LIMIT, 178.83,OTHER, 29.15, 344.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24083,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,MULTIPLAN,MULTIPLAN, 149.25,,OUTPCT LIMIT, 88.43,OTHER, 31.30, 162.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24084,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,MULTIPLAN,MULTIPLAN, 52.29,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24085,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,MULTIPLAN,MULTIPLAN, 52.29,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24086,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,MULTIPLAN,MULTIPLAN, 81.33,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24087,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,MULTIPLAN,MULTIPLAN, 81.33,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24088,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,MULTIPLAN,MULTIPLAN, 16.70,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24089,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,MULTIPLAN,MULTIPLAN, 319.65,,OUTPCT LIMIT, 180.72,OTHER, 30.61, 348.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24090,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,MULTIPLAN,MULTIPLAN, 553.25,,OUTPCT LIMIT, 302.95,OTHER, 11.66, 602.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24091,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,MULTIPLAN,MULTIPLAN, 134.85,,OUTPCT LIMIT, 81.90,OTHER, 36.67, 146.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24092,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,MULTIPLAN,MULTIPLAN, 210.62,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24093,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,MULTIPLAN,MULTIPLAN, 210.62,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24094,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,MULTIPLAN,MULTIPLAN, 210.62,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24095,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,MULTIPLAN,MULTIPLAN, 210.62,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24096,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,MULTIPLAN,MULTIPLAN, 146.56,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24097,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,MULTIPLAN,MULTIPLAN, 146.56,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24098,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,MULTIPLAN,MULTIPLAN, 187.71,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24099,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,MULTIPLAN,MULTIPLAN, 187.71,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24100,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,MULTIPLAN,MULTIPLAN, 93.84,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24101,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,MULTIPLAN,MULTIPLAN, 93.84,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24102,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,MULTIPLAN,MULTIPLAN, 134.28,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24103,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,MULTIPLAN,MULTIPLAN, 134.28,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24104,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,MULTIPLAN,MULTIPLAN, 134.28,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24105,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,MULTIPLAN,MULTIPLAN, 86.40,,OUTPCT LIMIT, 51.95,OTHER, 21.29, 94.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24106,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,MULTIPLAN,MULTIPLAN, 124.91,,OUTPCT LIMIT, 73.53,OTHER, 24.19, 136.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24107,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,MULTIPLAN,MULTIPLAN, 252.00,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24108,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,MULTIPLAN,MULTIPLAN, 252.00,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24109,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,MULTIPLAN,MULTIPLAN, 82.80,,OUTPCT LIMIT, 49.79,OTHER, 20.42, 90.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24110,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,MULTIPLAN,MULTIPLAN, 67.35,,OUTPCT LIMIT, 38.32,OTHER, 7.46, 73.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24111,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,MULTIPLAN,MULTIPLAN, 62.98,,OUTPCT LIMIT, 35.99,OTHER, 7.63, 68.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24112,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,MULTIPLAN,MULTIPLAN, 99.77,,OUTPCT LIMIT, 58.51,OTHER, 18.37, 108.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24113,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,MULTIPLAN,MULTIPLAN, 68.50,,OUTPCT LIMIT, 39.13,OTHER, 8.27, 74.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24114,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,MULTIPLAN,MULTIPLAN, 137.39,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24115,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,MULTIPLAN,MULTIPLAN, 137.39,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24116,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,MULTIPLAN,MULTIPLAN, 134.71,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24117,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,MULTIPLAN,MULTIPLAN, 134.71,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24118,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,MULTIPLAN,MULTIPLAN, 223.90,,OUTPCT LIMIT, 126.89,OTHER, 22.69, 243.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24119,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,MULTIPLAN,MULTIPLAN, 145.08,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24120,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,MULTIPLAN,MULTIPLAN, 145.08,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24121,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,MULTIPLAN,MULTIPLAN, 69.62,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24122,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,MULTIPLAN,MULTIPLAN, 69.62,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24123,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,MULTIPLAN,MULTIPLAN, 69.62,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24124,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,MULTIPLAN,MULTIPLAN, 38.14,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24125,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,MULTIPLAN,MULTIPLAN, 38.14,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24126,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,MULTIPLAN,MULTIPLAN, 55.89,,OUTPCT LIMIT, 31.87,OTHER, 6.50, 60.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24127,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,MULTIPLAN,MULTIPLAN, 68.85,,OUTPCT LIMIT, 39.10,OTHER, 7.32, 74.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24128,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,MULTIPLAN,MULTIPLAN, 133.35,,OUTPCT LIMIT, 76.33,OTHER, 16.72, 145.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24129,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,MULTIPLAN,MULTIPLAN, 182.48,,OUTPCT LIMIT, 103.71,OTHER, 19.75, 198.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24130,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,MULTIPLAN,MULTIPLAN, 97.27,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24131,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,MULTIPLAN,MULTIPLAN, 97.27,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24132,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,MULTIPLAN,MULTIPLAN, 97.27,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24133,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,MULTIPLAN,MULTIPLAN, 144.63,,OUTPCT LIMIT, 85.61,OTHER, 29.96, 157.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24134,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,MULTIPLAN,MULTIPLAN, 169.34,,OUTPCT LIMIT, 97.04,OTHER, 21.67, 184.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24135,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,MULTIPLAN,MULTIPLAN, 75.99,,OUTPCT LIMIT, 42.88,OTHER, 6.94, 82.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24136,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,MULTIPLAN,MULTIPLAN, 78.33,,OUTPCT LIMIT, 43.80,OTHER, 5.47, 85.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24137,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,MULTIPLAN,MULTIPLAN, 31.40,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24138,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,MULTIPLAN,MULTIPLAN, 31.40,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24139,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,MULTIPLAN,MULTIPLAN, 38.05,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24140,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,MULTIPLAN,MULTIPLAN, 38.05,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24141,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24142,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,MULTIPLAN,MULTIPLAN, 77.32,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24143,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,MULTIPLAN,MULTIPLAN, 78.32,,OUTPCT LIMIT, 44.71,OTHER, 9.31, 85.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24144,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,MULTIPLAN,MULTIPLAN, 66.88,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24145,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,MULTIPLAN,MULTIPLAN, 66.88,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24146,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,MULTIPLAN,MULTIPLAN, 35.10,,OUTPCT LIMIT, 19.92,OTHER, 3.66, 38.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24147,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,MULTIPLAN,MULTIPLAN, 57.30,,OUTPCT LIMIT, 32.63,OTHER, 6.46, 62.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24148,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,MULTIPLAN,MULTIPLAN, 167.05,,OUTPCT LIMIT, 96.77,OTHER, 25.78, 181.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24149,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,MULTIPLAN,MULTIPLAN, 223.82,,OUTPCT LIMIT, 129.31,OTHER, 33.04, 243.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24150,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,MULTIPLAN,MULTIPLAN, 233.10,,OUTPCT LIMIT, 130.54,OTHER, 17.06, 253.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24151,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,MULTIPLAN,MULTIPLAN, 172.50,,OUTPCT LIMIT, 98.34,OTHER, 19.93, 187.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24152,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,MULTIPLAN,MULTIPLAN, 154.35,,OUTPCT LIMIT, 89.00,OTHER, 22.06, 168.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24153,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,MULTIPLAN,MULTIPLAN, 174.60,,OUTPCT LIMIT, 98.22,OTHER, 14.66, 190.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24154,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,MULTIPLAN,MULTIPLAN, 94.55,,OUTPCT LIMIT, 54.63,OTHER, 13.99, 102.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24155,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,MULTIPLAN,MULTIPLAN, 117.90,,OUTPCT LIMIT, 70.40,OTHER, 27.00, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24156,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,MULTIPLAN,MULTIPLAN, 52.43,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24157,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,MULTIPLAN,MULTIPLAN, 52.09,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24158,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,MULTIPLAN,MULTIPLAN, 52.43,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24159,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,MULTIPLAN,MULTIPLAN, 23.40,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24160,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,MULTIPLAN,MULTIPLAN, 23.40,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24161,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,MULTIPLAN,MULTIPLAN, 23.40,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24162,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,MULTIPLAN,MULTIPLAN, 23.40,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24163,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,MULTIPLAN,MULTIPLAN, 73.98,,OUTPCT LIMIT, 41.60,OTHER, 6.14, 80.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24164,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,MULTIPLAN,MULTIPLAN, 46.80,,OUTPCT LIMIT, 26.32,OTHER, 3.89, 50.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24165,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,MULTIPLAN,MULTIPLAN, 63.51,,OUTPCT LIMIT, 36.35,OTHER, 7.93, 69.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24166,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,MULTIPLAN,MULTIPLAN, 153.00,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24167,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,MULTIPLAN,MULTIPLAN, 67.39,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24168,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,MULTIPLAN,MULTIPLAN, 136.37,,OUTPCT LIMIT, 76.67,OTHER, 11.26, 148.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24169,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,MULTIPLAN,MULTIPLAN, 1069.52,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24170,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,MULTIPLAN,MULTIPLAN, 290.70,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24171,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24172,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24173,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24174,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24175,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24176,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24177,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24178,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24179,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24180,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24181,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24182,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24183,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24184,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24185,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24186,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24187,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24188,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24189,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24190,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24191,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24192,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24193,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24194,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24195,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24196,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24197,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24198,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24199,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24200,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24201,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24202,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24203,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24204,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24205,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24206,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24207,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,MULTIPLAN,MULTIPLAN, 55.48,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24208,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24209,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24210,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24211,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24212,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,MULTIPLAN,MULTIPLAN, 28.89,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24213,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24214,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24215,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24216,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24217,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24218,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24219,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24220,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24221,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24222,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24223,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24224,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24225,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24226,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24227,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24228,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24229,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24230,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,MULTIPLAN,MULTIPLAN, 60.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24231,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,MULTIPLAN,MULTIPLAN, 337.28,,OUTPCT LIMIT, 189.29,OTHER, 26.45, 367.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24232,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,MULTIPLAN,MULTIPLAN, 205.93,,OUTPCT LIMIT, 115.17,OTHER, 14.46, 224.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24233,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,MULTIPLAN,MULTIPLAN, 119.97,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24234,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,MULTIPLAN,MULTIPLAN, 202.75,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24235,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,MULTIPLAN,MULTIPLAN, 83.10,,OUTPCT LIMIT, 48.91,OTHER, 16.07, 90.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24236,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,MULTIPLAN,MULTIPLAN, 78.75,,OUTPCT LIMIT, 45.23,OTHER, 10.51, 85.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24237,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,MULTIPLAN,MULTIPLAN, 28.21,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24238,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,MULTIPLAN,MULTIPLAN, 28.21,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24239,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,MULTIPLAN,MULTIPLAN, 101.03,,OUTPCT LIMIT, 59.25,OTHER, 18.65, 110.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24240,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,MULTIPLAN,MULTIPLAN, 157.13,,OUTPCT LIMIT, 93.98,OTHER, 36.65, 171.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24241,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,MULTIPLAN,MULTIPLAN, 237.11,,OUTPCT LIMIT, 137.37,OTHER, 36.65, 258.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24242,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,MULTIPLAN,MULTIPLAN, 134.46,,OUTPCT LIMIT, 78.46,OTHER, 23.14, 146.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24243,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,MULTIPLAN,MULTIPLAN, 117.23,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24244,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,MULTIPLAN,MULTIPLAN, 116.94,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24245,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,MULTIPLAN,MULTIPLAN, 130.35,,OUTPCT LIMIT, 77.69,OTHER, 29.26, 141.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24246,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,MULTIPLAN,MULTIPLAN, 108.27,,OUTPCT LIMIT, 63.19,OTHER, 18.65, 117.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24247,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,MULTIPLAN,MULTIPLAN, 108.12,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24248,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,MULTIPLAN,MULTIPLAN, 117.37,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24249,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,MULTIPLAN,MULTIPLAN, 127.31,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24250,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,MULTIPLAN,MULTIPLAN, 127.31,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24251,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,MULTIPLAN,MULTIPLAN, 127.31,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24252,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,MULTIPLAN,MULTIPLAN, 127.31,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24253,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,MULTIPLAN,MULTIPLAN, 127.46,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24254,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,MULTIPLAN,MULTIPLAN, 127.31,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24255,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,MULTIPLAN,MULTIPLAN, 108.77,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24256,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,MULTIPLAN,MULTIPLAN, 101.39,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24257,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,MULTIPLAN,MULTIPLAN, 143.10,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24258,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,MULTIPLAN,MULTIPLAN, 218.85,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24259,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,MULTIPLAN,MULTIPLAN, 211.28,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24260,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,MULTIPLAN,MULTIPLAN, 22.50,,OUTPCT LIMIT, 15.65,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24261,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,MULTIPLAN,MULTIPLAN, 134.14,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24262,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,MULTIPLAN,MULTIPLAN, 137.92,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24263,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,MULTIPLAN,MULTIPLAN, 143.74,,OUTPCT LIMIT, 85.12,OTHER, 29.96, 156.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24264,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,MULTIPLAN,MULTIPLAN, 177.52,,OUTPCT LIMIT, 103.45,OTHER, 29.96, 193.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24265,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,MULTIPLAN,MULTIPLAN, 121.77,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24266,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,MULTIPLAN,MULTIPLAN, 317.25,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24267,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,MULTIPLAN,MULTIPLAN, 89.87,,OUTPCT LIMIT, 50.54,OTHER, 7.46, 97.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24268,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,MULTIPLAN,MULTIPLAN, 149.68,,OUTPCT LIMIT, 88.87,OTHER, 32.17, 162.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24269,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,MULTIPLAN,MULTIPLAN, 108.90,,OUTPCT LIMIT, 66.43,OTHER, 30.83, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24270,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,MULTIPLAN,MULTIPLAN, 96.31,,OUTPCT LIMIT, 57.43,OTHER, 21.72, 104.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24271,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,MULTIPLAN,MULTIPLAN, 473.63,,OUTPCT LIMIT, 265.06,OTHER, 33.95, 515.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24272,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,MULTIPLAN,MULTIPLAN, 132.30,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24273,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,MULTIPLAN,MULTIPLAN, 132.30,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24274,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,MULTIPLAN,MULTIPLAN, 182.25,,OUTPCT LIMIT, 111.82,OTHER, 54.34, 198.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24275,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,MULTIPLAN,MULTIPLAN, 295.11,,OUTPCT LIMIT, 176.22,OTHER, 67.64, 321.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24276,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,MULTIPLAN,MULTIPLAN, 145.35,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24277,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,MULTIPLAN,MULTIPLAN, 145.35,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24278,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,MULTIPLAN,MULTIPLAN, 120.60,,OUTPCT LIMIT, 68.73,OTHER, 13.84, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24279,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,MULTIPLAN,MULTIPLAN, 146.81,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24280,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,MULTIPLAN,MULTIPLAN, 189.00,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24281,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,MULTIPLAN,MULTIPLAN, 120.60,,OUTPCT LIMIT, 70.10,OTHER, 19.60, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24282,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,MULTIPLAN,MULTIPLAN, 82.78,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24283,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,MULTIPLAN,MULTIPLAN, 82.78,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24284,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,MULTIPLAN,MULTIPLAN, 314.10,,OUTPCT LIMIT, 191.67,OTHER, 89.24, 342.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24285,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,MULTIPLAN,MULTIPLAN, 16.83,,OUTPCT LIMIT, 12.31,OTHER, 8.04, 18.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24286,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,MULTIPLAN,MULTIPLAN, 31.42,,OUTPCT LIMIT, 18.56,OTHER, 6.34, 34.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24287,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,MULTIPLAN,MULTIPLAN, 57.22,,OUTPCT LIMIT, 36.21,OTHER, 21.67, 62.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24288,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,MULTIPLAN,MULTIPLAN, 95.40,,OUTPCT LIMIT, 55.25,OTHER, 14.66, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24289,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,MULTIPLAN,MULTIPLAN, 65.81,,OUTPCT LIMIT, 40.13,OTHER, 18.58, 71.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24290,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,MULTIPLAN,MULTIPLAN, 114.30,,OUTPCT LIMIT, 66.54,OTHER, 19.00, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24291,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,MULTIPLAN,MULTIPLAN, 152.13,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24292,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,MULTIPLAN,MULTIPLAN, 152.13,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24293,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,MULTIPLAN,MULTIPLAN, 152.13,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24294,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,MULTIPLAN,MULTIPLAN, 41.71,,OUTPCT LIMIT, 26.75,OTHER, 17.29, 45.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24295,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,MULTIPLAN,MULTIPLAN, 87.24,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24296,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,MULTIPLAN,MULTIPLAN, 234.00,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24297,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,MULTIPLAN,MULTIPLAN, 84.60,,OUTPCT LIMIT, 50.83,OTHER, 20.72, 92.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24298,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,MULTIPLAN,MULTIPLAN, 98.10,,OUTPCT LIMIT, 59.00,OTHER, 24.26, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24299,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,MULTIPLAN,MULTIPLAN, 109.13,,OUTPCT LIMIT, 64.46,OTHER, 22.02, 118.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24300,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,MULTIPLAN,MULTIPLAN, 98.20,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24301,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,MULTIPLAN,MULTIPLAN, 98.20,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24302,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,MULTIPLAN,MULTIPLAN, 164.68,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24303,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,MULTIPLAN,MULTIPLAN, 99.12,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24304,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,MULTIPLAN,MULTIPLAN, 99.12,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24305,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,MULTIPLAN,MULTIPLAN, 110.70,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24306,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,MULTIPLAN,MULTIPLAN, 110.70,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24307,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,MULTIPLAN,MULTIPLAN, 71.10,,OUTPCT LIMIT, 43.51,OTHER, 20.72, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24308,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,MULTIPLAN,MULTIPLAN, 79.54,,OUTPCT LIMIT, 47.68,OTHER, 19.00, 86.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24309,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,MULTIPLAN,MULTIPLAN, 95.40,,OUTPCT LIMIT, 58.39,OTHER, 27.86, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24310,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,MULTIPLAN,MULTIPLAN, 134.06,,OUTPCT LIMIT, 77.47,OTHER, 19.86, 145.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24311,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,MULTIPLAN,MULTIPLAN, 106.53,,OUTPCT LIMIT, 62.50,OTHER, 19.74, 116.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24312,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,MULTIPLAN,MULTIPLAN, 78.54,,OUTPCT LIMIT, 46.75,OTHER, 17.35, 85.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24313,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,MULTIPLAN,MULTIPLAN, 68.40,,OUTPCT LIMIT, 41.14,OTHER, 16.94, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24314,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,MULTIPLAN,MULTIPLAN, 116.85,,OUTPCT LIMIT, 67.08,OTHER, 15.47, 127.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24315,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,MULTIPLAN,MULTIPLAN, 85.29,,OUTPCT LIMIT, 50.52,OTHER, 17.84, 92.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24316,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,MULTIPLAN,MULTIPLAN, 44.82,,OUTPCT LIMIT, 28.18,OTHER, 16.21, 48.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24317,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,MULTIPLAN,MULTIPLAN, 88.60,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24318,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,MULTIPLAN,MULTIPLAN, 88.60,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24319,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,MULTIPLAN,MULTIPLAN, 67.50,,OUTPCT LIMIT, 41.16,OTHER, 19.07, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24320,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,MULTIPLAN,MULTIPLAN, 75.90,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24321,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,MULTIPLAN,MULTIPLAN, 75.90,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24322,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,MULTIPLAN,MULTIPLAN, 75.90,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24323,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,MULTIPLAN,MULTIPLAN, 78.53,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24324,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,MULTIPLAN,MULTIPLAN, 81.23,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24325,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,MULTIPLAN,MULTIPLAN, 81.23,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24326,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,MULTIPLAN,MULTIPLAN, 82.65,,OUTPCT LIMIT, 49.38,OTHER, 19.07, 89.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24327,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,MULTIPLAN,MULTIPLAN, 139.51,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24328,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,MULTIPLAN,MULTIPLAN, 139.51,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24329,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,MULTIPLAN,MULTIPLAN, 658.61,,OUTPCT LIMIT, 361.76,OTHER, 18.55, 717.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24330,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,MULTIPLAN,MULTIPLAN, 288.90,,OUTPCT LIMIT, 161.64,OTHER, 20.54, 314.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24331,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,MULTIPLAN,MULTIPLAN, 251.79,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24332,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,MULTIPLAN,MULTIPLAN, 251.79,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24333,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,MULTIPLAN,MULTIPLAN, 137.61,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24334,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,MULTIPLAN,MULTIPLAN, 137.61,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24335,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,MULTIPLAN,MULTIPLAN, 137.61,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24336,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,MULTIPLAN,MULTIPLAN, 215.10,,OUTPCT LIMIT, 152.44,OTHER, 102.77, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24337,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,MULTIPLAN,MULTIPLAN, 387.77,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24338,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,MULTIPLAN,MULTIPLAN, 387.77,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24339,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,MULTIPLAN,MULTIPLAN, 387.77,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24340,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,MULTIPLAN,MULTIPLAN, 147.29,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24341,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,MULTIPLAN,MULTIPLAN, 147.29,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24342,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,MULTIPLAN,MULTIPLAN, 147.29,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24343,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,MULTIPLAN,MULTIPLAN, 147.29,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24344,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,MULTIPLAN,MULTIPLAN, 147.29,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24345,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,MULTIPLAN,MULTIPLAN, 267.40,,OUTPCT LIMIT, 146.86,OTHER, 7.46, 291.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24346,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,MULTIPLAN,MULTIPLAN, 99.00,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24347,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,MULTIPLAN,MULTIPLAN, 99.00,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24348,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,MULTIPLAN,MULTIPLAN, 99.00,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24349,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,MULTIPLAN,MULTIPLAN, 81.97,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24350,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,MULTIPLAN,MULTIPLAN, 77.90,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24351,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,MULTIPLAN,MULTIPLAN, 81.97,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24352,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,MULTIPLAN,MULTIPLAN, 387.77,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24353,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,MULTIPLAN,MULTIPLAN, 387.77,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24354,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,MULTIPLAN,MULTIPLAN, 352.35,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24355,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,MULTIPLAN,MULTIPLAN, 125.55,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24356,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,MULTIPLAN,MULTIPLAN, 125.55,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24357,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,MULTIPLAN,MULTIPLAN, 534.80,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24358,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,MULTIPLAN,MULTIPLAN, 534.80,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24359,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,MULTIPLAN,MULTIPLAN, 534.80,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24360,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,MULTIPLAN,MULTIPLAN, 534.80,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24361,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,MULTIPLAN,MULTIPLAN, 534.80,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24362,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,MULTIPLAN,MULTIPLAN, 534.80,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24363,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,MULTIPLAN,MULTIPLAN, 125.55,,OUTPCT LIMIT, 76.50,OTHER, 35.20, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24364,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,MULTIPLAN,MULTIPLAN, 234.90,,OUTPCT LIMIT, 149.18,OTHER, 91.25, 255.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24365,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,MULTIPLAN,MULTIPLAN, 143.51,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24366,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,MULTIPLAN,MULTIPLAN, 143.51,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24367,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,MULTIPLAN,MULTIPLAN, 50.73,,OUTPCT LIMIT, 30.76,OTHER, 13.60, 55.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24368,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,MULTIPLAN,MULTIPLAN, 128.43,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24369,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,MULTIPLAN,MULTIPLAN, 128.43,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24370,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,MULTIPLAN,MULTIPLAN, 138.26,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24371,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,MULTIPLAN,MULTIPLAN, 138.26,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24372,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,MULTIPLAN,MULTIPLAN, 140.48,,OUTPCT LIMIT, 78.99,OTHER, 11.64, 152.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24373,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,MULTIPLAN,MULTIPLAN, 81.10,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24374,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,MULTIPLAN,MULTIPLAN, 81.10,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24375,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,MULTIPLAN,MULTIPLAN, 81.10,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24376,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,MULTIPLAN,MULTIPLAN, 71.31,,OUTPCT LIMIT, 40.96,OTHER, 9.55, 77.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24377,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,MULTIPLAN,MULTIPLAN, 77.25,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24378,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,MULTIPLAN,MULTIPLAN, 77.25,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24379,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,MULTIPLAN,MULTIPLAN, 77.25,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24380,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,MULTIPLAN,MULTIPLAN, 146.50,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24381,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,MULTIPLAN,MULTIPLAN, 146.50,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24382,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,MULTIPLAN,MULTIPLAN, 132.44,,OUTPCT LIMIT, 74.74,OTHER, 12.11, 144.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24383,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,MULTIPLAN,MULTIPLAN, 160.90,,OUTPCT LIMIT, 91.00,OTHER, 15.55, 175.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24384,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,MULTIPLAN,MULTIPLAN, 120.28,,OUTPCT LIMIT, 68.31,OTHER, 12.82, 130.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24385,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,MULTIPLAN,MULTIPLAN, 29.70,,OUTPCT LIMIT, 17.74,OTHER, 6.84, 32.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24386,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,MULTIPLAN,MULTIPLAN, 37.65,,OUTPCT LIMIT, 22.99,OTHER, 10.78, 40.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24387,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,MULTIPLAN,MULTIPLAN, 52.20,,OUTPCT LIMIT, 29.95,OTHER, 6.84, 56.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24388,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,MULTIPLAN,MULTIPLAN, 72.70,,OUTPCT LIMIT, 42.41,OTHER, 12.46, 79.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24389,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,MULTIPLAN,MULTIPLAN, 50.93,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24390,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,MULTIPLAN,MULTIPLAN, 47.42,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24391,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,MULTIPLAN,MULTIPLAN, 47.42,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24392,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,MULTIPLAN,MULTIPLAN, 47.60,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24393,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,MULTIPLAN,MULTIPLAN, 47.60,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24394,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,MULTIPLAN,MULTIPLAN, 66.90,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24395,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,MULTIPLAN,MULTIPLAN, 66.90,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24396,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,MULTIPLAN,MULTIPLAN, 48.47,,OUTPCT LIMIT, 28.29,OTHER, 8.38, 52.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24397,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,MULTIPLAN,MULTIPLAN, 114.30,,OUTPCT LIMIT, 68.72,OTHER, 28.16, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24398,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,MULTIPLAN,MULTIPLAN, 544.23,,OUTPCT LIMIT, 299.39,OTHER, 17.26, 592.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24399,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,MULTIPLAN,MULTIPLAN, 68.42,,OUTPCT LIMIT, 40.67,OTHER, 14.88, 74.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24400,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,MULTIPLAN,MULTIPLAN, 72.11,,OUTPCT LIMIT, 43.08,OTHER, 16.61, 78.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24401,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,MULTIPLAN,MULTIPLAN, 215.10,,OUTPCT LIMIT, 121.25,OTHER, 19.08, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24402,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,MULTIPLAN,MULTIPLAN, 114.30,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24403,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,MULTIPLAN,MULTIPLAN, 173.70,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24404,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,MULTIPLAN,MULTIPLAN, 173.71,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24405,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,MULTIPLAN,MULTIPLAN, 173.70,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24406,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,MULTIPLAN,MULTIPLAN, 173.70,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24407,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,MULTIPLAN,MULTIPLAN, 173.70,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24408,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,MULTIPLAN,MULTIPLAN, 339.44,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24409,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,MULTIPLAN,MULTIPLAN, 339.44,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24410,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,MULTIPLAN,MULTIPLAN, 141.42,,OUTPCT LIMIT, 100.71,OTHER, 67.57, 153.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24411,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,MULTIPLAN,MULTIPLAN, 381.12,,OUTPCT LIMIT, 221.47,OTHER, 61.69, 415.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24412,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,MULTIPLAN,MULTIPLAN, 118.70,,OUTPCT LIMIT, 76.43,OTHER, 50.53, 129.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24413,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,MULTIPLAN,MULTIPLAN, 434.70,,OUTPCT LIMIT, 265.03,OTHER, 122.54, 473.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24414,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,MULTIPLAN,MULTIPLAN, 173.71,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24415,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,MULTIPLAN,MULTIPLAN, 135.00,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24416,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,MULTIPLAN,MULTIPLAN, 135.00,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24417,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,MULTIPLAN,MULTIPLAN, 558.05,,OUTPCT LIMIT, 445.68,OTHER, 266.63, 607.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24418,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,MULTIPLAN,MULTIPLAN, 90.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24419,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,MULTIPLAN,MULTIPLAN, 90.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24420,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,MULTIPLAN,MULTIPLAN, 90.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24421,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,MULTIPLAN,MULTIPLAN, 335.36,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24422,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,MULTIPLAN,MULTIPLAN, 335.36,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24423,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24424,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,MULTIPLAN,MULTIPLAN, 297.90,,OUTPCT LIMIT, 173.66,OTHER, 50.53, 324.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24425,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,MULTIPLAN,MULTIPLAN, 114.30,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24426,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,MULTIPLAN,MULTIPLAN, 157.68,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24427,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,MULTIPLAN,MULTIPLAN, 550.75,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24428,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,MULTIPLAN,MULTIPLAN, 242.97,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24429,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,MULTIPLAN,MULTIPLAN, 242.97,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24430,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,MULTIPLAN,MULTIPLAN, 104.28,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24431,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,MULTIPLAN,MULTIPLAN, 104.28,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24432,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,MULTIPLAN,MULTIPLAN, 71.10,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24433,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,MULTIPLAN,MULTIPLAN, 71.10,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24434,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,MULTIPLAN,MULTIPLAN, 71.10,,OUTPCT LIMIT, 44.25,OTHER, 23.81, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24435,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,MULTIPLAN,MULTIPLAN, 22.50,,OUTPCT LIMIT, 17.88,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24436,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,MULTIPLAN,MULTIPLAN, 174.41,,OUTPCT LIMIT, 100.14,OTHER, 23.14, 189.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24437,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,MULTIPLAN,MULTIPLAN, 1313.10,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24438,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,MULTIPLAN,MULTIPLAN, 1313.10,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24439,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,MULTIPLAN,MULTIPLAN, 93.60,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24440,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,MULTIPLAN,MULTIPLAN, 93.60,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24441,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,MULTIPLAN,MULTIPLAN, 499.50,,OUTPCT LIMIT, 294.34,OTHER, 97.97, 543.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24442,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24443,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24444,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,MULTIPLAN,MULTIPLAN, 27.90,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24445,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,MULTIPLAN,MULTIPLAN, 27.90,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24446,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,MULTIPLAN,MULTIPLAN, 101.17,,OUTPCT LIMIT, 56.81,OTHER, 8.06, 110.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24447,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,MULTIPLAN,MULTIPLAN, 69.05,,OUTPCT LIMIT, 39.98,OTHER, 10.56, 75.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24448,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,MULTIPLAN,MULTIPLAN, 69.30,,OUTPCT LIMIT, 41.73,OTHER, 17.35, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24449,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,MULTIPLAN,MULTIPLAN, 5339.19,,OUTPCT LIMIT, 3802.17,OTHER, 2550.94, 5813.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24450,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,MULTIPLAN,MULTIPLAN, 101.39,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24451,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,MULTIPLAN,MULTIPLAN, 101.39,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24452,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,MULTIPLAN,MULTIPLAN, 26.55,,OUTPCT LIMIT, 23.30,OTHER, 12.69, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24453,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,MULTIPLAN,MULTIPLAN, 53.55,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24454,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,MULTIPLAN,MULTIPLAN, 26.78,,OUTPCT LIMIT, 23.42,OTHER, 12.79, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24455,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,MULTIPLAN,MULTIPLAN, 116.10,,OUTPCT LIMIT, 82.68,OTHER, 55.47, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24456,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24457,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,MULTIPLAN,MULTIPLAN, 137.70,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24458,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,MULTIPLAN,MULTIPLAN, 137.70,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24459,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,MULTIPLAN,MULTIPLAN, 125.06,,OUTPCT LIMIT, 89.06,OTHER, 59.75, 136.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24460,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,MULTIPLAN,MULTIPLAN, 45.00,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24461,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,MULTIPLAN,MULTIPLAN, 45.00,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24462,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,MULTIPLAN,MULTIPLAN, 534.05,,OUTPCT LIMIT, 356.50,OTHER, 255.16, 581.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24463,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,MULTIPLAN,MULTIPLAN, 1115.81,,OUTPCT LIMIT, 687.64,OTHER, 345.38, 1214.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24464,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,MULTIPLAN,MULTIPLAN, 283.05,,OUTPCT LIMIT, 201.57,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24465,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24466,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24467,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,MULTIPLAN,MULTIPLAN, 76.50,,OUTPCT LIMIT, 60.00,OTHER, 36.55, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24468,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,MULTIPLAN,MULTIPLAN, 46.31,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24469,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,MULTIPLAN,MULTIPLAN, 46.31,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24470,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24471,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24472,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24473,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,MULTIPLAN,MULTIPLAN, 9.90,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24474,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,MULTIPLAN,MULTIPLAN, 9.90,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24475,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,MULTIPLAN,MULTIPLAN, 9.90,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24476,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,MULTIPLAN,MULTIPLAN, 9.90,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24477,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,MULTIPLAN,MULTIPLAN, 71.77,,OUTPCT LIMIT, 51.11,OTHER, 34.29, 78.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24478,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,MULTIPLAN,MULTIPLAN, 123.04,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24479,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,MULTIPLAN,MULTIPLAN, 123.04,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24480,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24481,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,MULTIPLAN,MULTIPLAN, 142.02,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24482,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,MULTIPLAN,MULTIPLAN, 142.02,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24483,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24484,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24485,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,MULTIPLAN,MULTIPLAN, 153.82,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24486,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,MULTIPLAN,MULTIPLAN, 153.82,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24487,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,MULTIPLAN,MULTIPLAN, 9.00,,OUTPCT LIMIT, 12.78,OTHER, 4.30, 33.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24488,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,MULTIPLAN,MULTIPLAN, 29.75,,OUTPCT LIMIT, 17.36,OTHER, 5.09, 32.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24489,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,MULTIPLAN,MULTIPLAN, 273.52,,OUTPCT LIMIT, 184.48,OTHER, 130.68, 297.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24490,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,MULTIPLAN,MULTIPLAN, 306.46,,OUTPCT LIMIT, 202.35,OTHER, 146.42, 333.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24491,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,MULTIPLAN,MULTIPLAN, 133.15,,OUTPCT LIMIT, 99.37,OTHER, 63.61, 144.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24492,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,MULTIPLAN,MULTIPLAN, 136.86,,OUTPCT LIMIT, 88.44,OTHER, 59.56, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24493,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,MULTIPLAN,MULTIPLAN, 176.28,,OUTPCT LIMIT, 131.72,OTHER, 84.22, 191.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24494,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,MULTIPLAN,MULTIPLAN, 173.31,,OUTPCT LIMIT, 117.05,OTHER, 82.81, 188.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24495,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,MULTIPLAN,MULTIPLAN, 264.80,,OUTPCT LIMIT, 179.75,OTHER, 126.51, 288.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24496,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,MULTIPLAN,MULTIPLAN, 229.10,,OUTPCT LIMIT, 158.52,OTHER, 109.46, 249.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24497,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,MULTIPLAN,MULTIPLAN, 276.71,,OUTPCT LIMIT, 186.21,OTHER, 132.20, 301.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24498,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,MULTIPLAN,MULTIPLAN, 132.40,,OUTPCT LIMIT, 83.96,OTHER, 50.93, 144.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24499,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,MULTIPLAN,MULTIPLAN, 213.48,,OUTPCT LIMIT, 167.44,OTHER, 102.00, 232.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24500,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,MULTIPLAN,MULTIPLAN, 222.40,,OUTPCT LIMIT, 172.28,OTHER, 106.26, 242.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24501,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,MULTIPLAN,MULTIPLAN, 53.56,,OUTPCT LIMIT, 49.86,OTHER, 25.59, 87.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24502,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,MULTIPLAN,MULTIPLAN, 223.15,,OUTPCT LIMIT, 141.43,OTHER, 85.51, 242.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24503,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,MULTIPLAN,MULTIPLAN, 95.06,,OUTPCT LIMIT, 69.71,OTHER, 45.42, 103.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24504,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,MULTIPLAN,MULTIPLAN, 252.15,,OUTPCT LIMIT, 177.65,OTHER, 120.47, 274.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24505,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,MULTIPLAN,MULTIPLAN, 273.91,,OUTPCT LIMIT, 189.46,OTHER, 130.87, 298.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24506,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,MULTIPLAN,MULTIPLAN, 440.66,,OUTPCT LIMIT, 279.93,OTHER, 171.54, 479.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24507,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,MULTIPLAN,MULTIPLAN, 413.14,,OUTPCT LIMIT, 265.00,OTHER, 171.54, 449.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24508,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,MULTIPLAN,MULTIPLAN, 226.43,,OUTPCT LIMIT, 149.90,OTHER, 108.18, 246.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24509,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,MULTIPLAN,MULTIPLAN, 287.60,,OUTPCT LIMIT, 167.02,OTHER, 46.09, 313.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24510,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,MULTIPLAN,MULTIPLAN, 120.03,,OUTPCT LIMIT, 76.10,OTHER, 46.09, 130.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24511,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,MULTIPLAN,MULTIPLAN, 251.34,,OUTPCT LIMIT, 147.35,OTHER, 46.09, 273.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24512,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,MULTIPLAN,MULTIPLAN, 364.23,,OUTPCT LIMIT, 227.22,OTHER, 124.32, 396.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24513,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,MULTIPLAN,MULTIPLAN, 490.05,,OUTPCT LIMIT, 295.49,OTHER, 124.32, 533.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24514,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,MULTIPLAN,MULTIPLAN, 156.29,,OUTPCT LIMIT, 114.40,OTHER, 74.67, 170.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24515,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,MULTIPLAN,MULTIPLAN, 232.01,,OUTPCT LIMIT, 155.48,OTHER, 110.85, 252.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24516,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,MULTIPLAN,MULTIPLAN, 35.96,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24517,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,MULTIPLAN,MULTIPLAN, 35.96,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24518,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,MULTIPLAN,MULTIPLAN, 35.96,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24519,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,MULTIPLAN,MULTIPLAN, 17.60,,OUTPCT LIMIT, 36.72,OTHER, 8.41, 114.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24520,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,MULTIPLAN,MULTIPLAN, 331.52,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24521,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,MULTIPLAN,MULTIPLAN, 331.52,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24522,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,MULTIPLAN,MULTIPLAN, 818.67,,OUTPCT LIMIT, 526.62,OTHER, 346.21, 891.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24523,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 290.83,OTHER, 143.52, 346.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24524,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,MULTIPLAN,MULTIPLAN, 299.94,,OUTPCT LIMIT, 266.67,OTHER, 147.17, 326.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24525,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,MULTIPLAN,MULTIPLAN, 277.20,,OUTPCT LIMIT, 162.12,OTHER, 49.24, 301.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24526,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,MULTIPLAN,MULTIPLAN, 223.20,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24527,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,MULTIPLAN,MULTIPLAN, 223.20,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24528,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,MULTIPLAN,MULTIPLAN, 285.30,,OUTPCT LIMIT, 166.97,OTHER, 51.13, 310.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24529,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,MULTIPLAN,MULTIPLAN, 78.85,,OUTPCT LIMIT, 54.96,OTHER, 37.67, 85.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24530,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,MULTIPLAN,MULTIPLAN, 136.86,,OUTPCT LIMIT, 86.43,OTHER, 51.13, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24531,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,MULTIPLAN,MULTIPLAN, 1464.01,,OUTPCT LIMIT, 950.56,OTHER, 656.16, 1594.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24532,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 375.80,OTHER, 121.44, 656.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24533,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,MULTIPLAN,MULTIPLAN, 837.00,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24534,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,MULTIPLAN,MULTIPLAN, 837.00,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24535,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24536,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24537,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,MULTIPLAN,MULTIPLAN, 992.04,,OUTPCT LIMIT, 591.97,OTHER, 225.62, 1080.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24538,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24539,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,MULTIPLAN,MULTIPLAN, 419.12,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24540,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,MULTIPLAN,MULTIPLAN, 419.12,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24541,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 197.77,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24542,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,MULTIPLAN,MULTIPLAN, 939.84,,OUTPCT LIMIT, 563.65,OTHER, 225.62, 1023.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24543,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24544,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,MULTIPLAN,MULTIPLAN, 146.70,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24545,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,MULTIPLAN,MULTIPLAN, 146.70,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24546,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24547,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24548,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,MULTIPLAN,MULTIPLAN, 450.00,,OUTPCT LIMIT, 297.88,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24549,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24550,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,MULTIPLAN,MULTIPLAN, 420.98,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24551,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,MULTIPLAN,MULTIPLAN, 420.98,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24552,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24553,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24554,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MULTIPLAN,MULTIPLAN, 1142.51,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24555,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MULTIPLAN,MULTIPLAN, 1142.51,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24556,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,MULTIPLAN,MULTIPLAN, 607.03,,OUTPCT LIMIT, 383.08,OTHER, 225.62, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24557,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,MULTIPLAN,MULTIPLAN, 1142.51,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24558,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24559,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24560,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24561,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24562,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,MULTIPLAN,MULTIPLAN, 607.03,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24563,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,MULTIPLAN,MULTIPLAN, 607.03,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24564,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,MULTIPLAN,MULTIPLAN, 607.03,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24565,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,MULTIPLAN,MULTIPLAN, 607.03,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24566,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24567,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24568,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24569,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24570,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,MULTIPLAN,MULTIPLAN, 1108.92,,OUTPCT LIMIT, 655.39,OTHER, 225.62, 1207.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24571,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24572,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,MULTIPLAN,MULTIPLAN, 2331.90,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24573,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,MULTIPLAN,MULTIPLAN, 1259.53,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24574,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,MULTIPLAN,MULTIPLAN, 392.40,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24575,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,MULTIPLAN,MULTIPLAN, 82.80,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24576,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,MULTIPLAN,MULTIPLAN, 948.04,,OUTPCT LIMIT, 547.41,OTHER, 138.71, 1032.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24577,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,MULTIPLAN,MULTIPLAN, 217.43,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24578,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,MULTIPLAN,MULTIPLAN, 217.43,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24579,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,MULTIPLAN,MULTIPLAN, 263.28,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24580,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,MULTIPLAN,MULTIPLAN, 263.28,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24581,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,MULTIPLAN,MULTIPLAN, 551.13,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24582,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,MULTIPLAN,MULTIPLAN, 722.70,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24583,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,MULTIPLAN,MULTIPLAN, 793.80,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24584,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,MULTIPLAN,MULTIPLAN, 551.13,,OUTPCT LIMIT, 332.46,OTHER, 140.42, 600.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24585,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,MULTIPLAN,MULTIPLAN, 335.48,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24586,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,MULTIPLAN,MULTIPLAN, 335.48,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24587,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,MULTIPLAN,MULTIPLAN, 217.43,,OUTPCT LIMIT, 174.98,OTHER, 103.88, 239.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24588,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,MULTIPLAN,MULTIPLAN, 217.43,,OUTPCT LIMIT, 136.10,OTHER, 76.16, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24589,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,MULTIPLAN,MULTIPLAN, 155.70,,OUTPCT LIMIT, 140.33,OTHER, 74.39, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24590,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,MULTIPLAN,MULTIPLAN, 382.50,,OUTPCT LIMIT, 228.33,OTHER, 87.35, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24591,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,MULTIPLAN,MULTIPLAN, 48.01,,OUTPCT LIMIT, 34.19,OTHER, 22.94, 52.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24592,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,MULTIPLAN,MULTIPLAN, 93.60,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24593,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,MULTIPLAN,MULTIPLAN, 294.89,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24594,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,MULTIPLAN,MULTIPLAN, 294.89,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24595,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,MULTIPLAN,MULTIPLAN, 129.09,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24596,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,MULTIPLAN,MULTIPLAN, 129.09,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24597,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,MULTIPLAN,MULTIPLAN, 662.57,,OUTPCT LIMIT, 415.63,OTHER, 235.80, 721.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24598,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,MULTIPLAN,MULTIPLAN, 2925.00,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24599,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,MULTIPLAN,MULTIPLAN, 2925.00,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24600,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,MULTIPLAN,MULTIPLAN, 3510.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24601,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,MULTIPLAN,MULTIPLAN, 3510.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24602,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,MULTIPLAN,MULTIPLAN, 3510.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24603,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,MULTIPLAN,MULTIPLAN, 244.10,,OUTPCT LIMIT, 152.82,OTHER, 85.61, 265.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24604,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,MULTIPLAN,MULTIPLAN, 266.65,,OUTPCT LIMIT, 165.98,OTHER, 89.47, 290.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24605,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,MULTIPLAN,MULTIPLAN, 432.24,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24606,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,MULTIPLAN,MULTIPLAN, 432.24,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24607,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,MULTIPLAN,MULTIPLAN, 162.18,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24608,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,MULTIPLAN,MULTIPLAN, 162.18,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24609,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,MULTIPLAN,MULTIPLAN, 514.49,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24610,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,MULTIPLAN,MULTIPLAN, 514.49,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24611,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,MULTIPLAN,MULTIPLAN, 514.49,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24612,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,MULTIPLAN,MULTIPLAN, 148.23,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24613,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,MULTIPLAN,MULTIPLAN, 148.29,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24614,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,MULTIPLAN,MULTIPLAN, 176.79,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24615,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,MULTIPLAN,MULTIPLAN, 176.79,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24616,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,MULTIPLAN,MULTIPLAN, 129.55,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24617,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,MULTIPLAN,MULTIPLAN, 129.55,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24618,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,MULTIPLAN,MULTIPLAN, 138.50,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24619,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,MULTIPLAN,MULTIPLAN, 138.50,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24620,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,MULTIPLAN,MULTIPLAN, 53.55,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24621,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,MULTIPLAN,MULTIPLAN, 53.55,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24622,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,MULTIPLAN,MULTIPLAN, 270.76,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24623,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,MULTIPLAN,MULTIPLAN, 270.76,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24624,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,MULTIPLAN,MULTIPLAN, 153.84,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24625,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,MULTIPLAN,MULTIPLAN, 153.84,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24626,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,MULTIPLAN,MULTIPLAN, 155.25,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24627,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,MULTIPLAN,MULTIPLAN, 155.25,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24628,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,MULTIPLAN,MULTIPLAN, 79.16,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24629,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,MULTIPLAN,MULTIPLAN, 79.16,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24630,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,MULTIPLAN,MULTIPLAN, 86.89,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24631,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,MULTIPLAN,MULTIPLAN, 86.89,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24632,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,MULTIPLAN,MULTIPLAN, 95.21,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24633,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,MULTIPLAN,MULTIPLAN, 95.21,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24634,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,MULTIPLAN,MULTIPLAN, 95.21,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24635,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,MULTIPLAN,MULTIPLAN, 378.00,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24636,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,MULTIPLAN,MULTIPLAN, 121.37,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24637,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,MULTIPLAN,MULTIPLAN, 121.37,,OUTPCT LIMIT, 72.71,OTHER, 28.82, 132.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24638,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,MULTIPLAN,MULTIPLAN, 110.59,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24639,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,MULTIPLAN,MULTIPLAN, 110.52,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24640,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,MULTIPLAN,MULTIPLAN, 110.59,,OUTPCT LIMIT, 74.35,OTHER, 52.84, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24641,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,MULTIPLAN,MULTIPLAN, 117.95,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24642,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,MULTIPLAN,MULTIPLAN, 117.95,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24643,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,MULTIPLAN,MULTIPLAN, 117.95,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24644,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,MULTIPLAN,MULTIPLAN, 85.62,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24645,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,MULTIPLAN,MULTIPLAN, 85.62,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24646,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,MULTIPLAN,MULTIPLAN, 60.86,,OUTPCT LIMIT, 47.68,OTHER, 29.08, 66.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24647,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,MULTIPLAN,MULTIPLAN, 161.10,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24648,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,MULTIPLAN,MULTIPLAN, 161.10,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24649,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,MULTIPLAN,MULTIPLAN, 161.10,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24650,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,MULTIPLAN,MULTIPLAN, 193.50,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24651,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,MULTIPLAN,MULTIPLAN, 193.50,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24652,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,MULTIPLAN,MULTIPLAN, 193.50,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24653,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,MULTIPLAN,MULTIPLAN, 110.40,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24654,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,MULTIPLAN,MULTIPLAN, 110.40,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24655,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,MULTIPLAN,MULTIPLAN, 110.40,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24656,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,MULTIPLAN,MULTIPLAN, 39.60,,OUTPCT LIMIT, 30.33,OTHER, 18.92, 43.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24657,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,MULTIPLAN,MULTIPLAN, 238.54,,OUTPCT LIMIT, 178.52,OTHER, 113.97, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24658,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,MULTIPLAN,MULTIPLAN, 283.05,,OUTPCT LIMIT, 202.67,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24659,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,MULTIPLAN,MULTIPLAN, 267.99,,OUTPCT LIMIT, 194.50,OTHER, 128.04, 291.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24660,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,MULTIPLAN,MULTIPLAN, 133.52,,OUTPCT LIMIT, 106.37,OTHER, 63.79, 145.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24661,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,MULTIPLAN,MULTIPLAN, 228.90,,OUTPCT LIMIT, 173.75,OTHER, 109.36, 249.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24662,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,MULTIPLAN,MULTIPLAN, 241.96,,OUTPCT LIMIT, 180.83,OTHER, 115.60, 263.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24663,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,MULTIPLAN,MULTIPLAN, 285.56,,OUTPCT LIMIT, 204.49,OTHER, 136.43, 310.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24664,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,MULTIPLAN,MULTIPLAN, 137.92,,OUTPCT LIMIT, 108.91,OTHER, 65.89, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24665,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,MULTIPLAN,MULTIPLAN, 108.64,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24666,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,MULTIPLAN,MULTIPLAN, 108.64,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24667,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,MULTIPLAN,MULTIPLAN, 108.64,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24668,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,MULTIPLAN,MULTIPLAN, 66.06,,OUTPCT LIMIT, 44.69,OTHER, 31.56, 71.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24669,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,MULTIPLAN,MULTIPLAN, 114.89,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24670,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,MULTIPLAN,MULTIPLAN, 114.89,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24671,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,MULTIPLAN,MULTIPLAN, 79.76,,OUTPCT LIMIT, 59.17,OTHER, 38.11, 86.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24672,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,MULTIPLAN,MULTIPLAN, 104.40,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24673,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,MULTIPLAN,MULTIPLAN, 104.40,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24674,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,MULTIPLAN,MULTIPLAN, 104.40,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24675,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,MULTIPLAN,MULTIPLAN, 26.10,,OUTPCT LIMIT, 68.90,OTHER, 12.81, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24676,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,MULTIPLAN,MULTIPLAN, 129.38,,OUTPCT LIMIT, 93.12,OTHER, 61.82, 140.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24677,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,MULTIPLAN,MULTIPLAN, 108.90,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24678,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,MULTIPLAN,MULTIPLAN, 238.54,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24679,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MULTIPLAN,MULTIPLAN, 111.60,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24680,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MULTIPLAN,MULTIPLAN, 111.60,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24681,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,MULTIPLAN,MULTIPLAN, 111.60,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24682,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,MULTIPLAN,MULTIPLAN, 67.50,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24683,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,MULTIPLAN,MULTIPLAN, 93.60,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24684,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,MULTIPLAN,MULTIPLAN, 126.90,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24685,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,MULTIPLAN,MULTIPLAN, 93.60,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24686,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,MULTIPLAN,MULTIPLAN, 126.90,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24687,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,MULTIPLAN,MULTIPLAN, 67.50,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24688,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,MULTIPLAN,MULTIPLAN, 67.50,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24689,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,MULTIPLAN,MULTIPLAN, 270.00,,OUTPCT LIMIT, 192.27,OTHER, 129.00, 294.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24690,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24691,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24692,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,MULTIPLAN,MULTIPLAN, 217.43,,OUTPCT LIMIT, 145.27,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24693,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,MULTIPLAN,MULTIPLAN, 133.88,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24694,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,MULTIPLAN,MULTIPLAN, 133.88,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24695,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,MULTIPLAN,MULTIPLAN, 226.86,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24696,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,MULTIPLAN,MULTIPLAN, 226.86,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24697,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,MULTIPLAN,MULTIPLAN, 354.96,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24698,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,MULTIPLAN,MULTIPLAN, 354.96,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24699,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,MULTIPLAN,MULTIPLAN, 442.17,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24700,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,MULTIPLAN,MULTIPLAN, 442.17,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24701,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,MULTIPLAN,MULTIPLAN, 42.84,,OUTPCT LIMIT, 30.51,OTHER, 20.47, 46.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24702,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,MULTIPLAN,MULTIPLAN, 93.33,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24703,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,MULTIPLAN,MULTIPLAN, 93.33,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24704,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,MULTIPLAN,MULTIPLAN, 156.06,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24705,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,MULTIPLAN,MULTIPLAN, 156.06,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24706,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,MULTIPLAN,MULTIPLAN, 230.27,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24707,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,MULTIPLAN,MULTIPLAN, 230.27,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24708,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,MULTIPLAN,MULTIPLAN, 308.30,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24709,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,MULTIPLAN,MULTIPLAN, 308.30,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24710,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,MULTIPLAN,MULTIPLAN, 306.00,,OUTPCT LIMIT, 272.06,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24711,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,MULTIPLAN,MULTIPLAN, 378.90,,OUTPCT LIMIT, 336.87,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24712,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,MULTIPLAN,MULTIPLAN, 130.50,,OUTPCT LIMIT, 111.61,OTHER, 64.03, 142.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24713,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,MULTIPLAN,MULTIPLAN, 159.30,,OUTPCT LIMIT, 149.82,OTHER, 78.16, 173.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24714,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,MULTIPLAN,MULTIPLAN, 230.40,,OUTPCT LIMIT, 220.11,OTHER, 113.05, 250.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24715,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,MULTIPLAN,MULTIPLAN, 242.03,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24716,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,MULTIPLAN,MULTIPLAN, 242.03,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24717,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,MULTIPLAN,MULTIPLAN, 225.90,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24718,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,MULTIPLAN,MULTIPLAN, 225.90,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24719,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,MULTIPLAN,MULTIPLAN, 374.40,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24720,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,MULTIPLAN,MULTIPLAN, 374.40,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24721,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,MULTIPLAN,MULTIPLAN, 266.40,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24722,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,MULTIPLAN,MULTIPLAN, 266.40,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24723,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,MULTIPLAN,MULTIPLAN, 591.61,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24724,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,MULTIPLAN,MULTIPLAN, 591.61,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24725,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,MULTIPLAN,MULTIPLAN, 306.00,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24726,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,MULTIPLAN,MULTIPLAN, 306.00,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24727,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,MULTIPLAN,MULTIPLAN, 927.96,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24728,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,MULTIPLAN,MULTIPLAN, 927.96,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24729,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,MULTIPLAN,MULTIPLAN, 378.90,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24730,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,MULTIPLAN,MULTIPLAN, 378.90,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24731,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,MULTIPLAN,MULTIPLAN, 1547.80,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24732,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,MULTIPLAN,MULTIPLAN, 1547.80,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24733,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,MULTIPLAN,MULTIPLAN, 450.90,,OUTPCT LIMIT, 429.06,OTHER, 221.24, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24734,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,MULTIPLAN,MULTIPLAN, 2475.70,,OUTPCT LIMIT, 1514.86,OTHER, 720.78, 2695.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24735,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,MULTIPLAN,MULTIPLAN, 907.57,,OUTPCT LIMIT, 646.30,OTHER, 433.62, 988.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24736,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,MULTIPLAN,MULTIPLAN, 27.00,,OUTPCT LIMIT, 19.23,OTHER, 12.90, 29.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24737,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,MULTIPLAN,MULTIPLAN, 150.71,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24738,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,MULTIPLAN,MULTIPLAN, 150.71,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24739,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,MULTIPLAN,MULTIPLAN, 237.15,,OUTPCT LIMIT, 167.97,OTHER, 113.31, 258.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24740,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,MULTIPLAN,MULTIPLAN, 247.10,,OUTPCT LIMIT, 173.37,OTHER, 118.06, 269.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24741,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,MULTIPLAN,MULTIPLAN, 257.81,,OUTPCT LIMIT, 179.18,OTHER, 123.17, 280.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24742,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,MULTIPLAN,MULTIPLAN, 291.47,,OUTPCT LIMIT, 197.44,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24743,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,MULTIPLAN,MULTIPLAN, 283.05,,OUTPCT LIMIT, 192.88,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24744,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,MULTIPLAN,MULTIPLAN, 326.66,,OUTPCT LIMIT, 232.62,OTHER, 156.07, 355.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24745,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,MULTIPLAN,MULTIPLAN, 354.96,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24746,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,MULTIPLAN,MULTIPLAN, 213.44,,OUTPCT LIMIT, 155.10,OTHER, 101.97, 232.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24747,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,MULTIPLAN,MULTIPLAN, 227.97,,OUTPCT LIMIT, 162.99,OTHER, 108.92, 248.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24748,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,MULTIPLAN,MULTIPLAN, 248.63,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24749,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,MULTIPLAN,MULTIPLAN, 248.63,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24750,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,MULTIPLAN,MULTIPLAN, 248.63,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24751,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,MULTIPLAN,MULTIPLAN, 253.98,,OUTPCT LIMIT, 177.10,OTHER, 121.35, 276.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24752,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,MULTIPLAN,MULTIPLAN, 270.81,,OUTPCT LIMIT, 192.85,OTHER, 129.39, 294.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24753,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,MULTIPLAN,MULTIPLAN, 291.47,,OUTPCT LIMIT, 207.56,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24754,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,MULTIPLAN,MULTIPLAN, 78.03,,OUTPCT LIMIT, 55.57,OTHER, 37.28, 84.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24755,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,MULTIPLAN,MULTIPLAN, 133.88,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24756,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,MULTIPLAN,MULTIPLAN, 63.00,,OUTPCT LIMIT, 44.86,OTHER, 30.10, 68.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24757,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,MULTIPLAN,MULTIPLAN, 239.45,,OUTPCT LIMIT, 170.52,OTHER, 114.40, 260.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24758,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,MULTIPLAN,MULTIPLAN, 47.59,,OUTPCT LIMIT, 33.14,OTHER, 22.74, 51.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24759,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,MULTIPLAN,MULTIPLAN, 58.91,,OUTPCT LIMIT, 39.28,OTHER, 28.14, 64.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24760,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,MULTIPLAN,MULTIPLAN, 84.94,,OUTPCT LIMIT, 60.49,OTHER, 40.58, 92.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24761,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,MULTIPLAN,MULTIPLAN, 19.80,,OUTPCT LIMIT, 14.10,OTHER, 9.46, 21.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24762,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,MULTIPLAN,MULTIPLAN, 19.80,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24763,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,MULTIPLAN,MULTIPLAN, 133.88,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24764,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,MULTIPLAN,MULTIPLAN, 229.50,,OUTPCT LIMIT, 148.65,OTHER, 101.33, 249.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24765,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,MULTIPLAN,MULTIPLAN, 247.50,,OUTPCT LIMIT, 166.04,OTHER, 118.25, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24766,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,MULTIPLAN,MULTIPLAN, 11.48,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24767,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,MULTIPLAN,MULTIPLAN, 11.48,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24768,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,MULTIPLAN,MULTIPLAN, 346.50,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24769,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,MULTIPLAN,MULTIPLAN, 346.50,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24770,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,MULTIPLAN,MULTIPLAN, 546.30,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24771,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,MULTIPLAN,MULTIPLAN, 546.30,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24772,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,MULTIPLAN,MULTIPLAN, 319.50,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24773,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,MULTIPLAN,MULTIPLAN, 319.50,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24774,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,MULTIPLAN,MULTIPLAN, 460.80,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24775,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,MULTIPLAN,MULTIPLAN, 460.80,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24776,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,MULTIPLAN,MULTIPLAN, 790.20,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24777,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,MULTIPLAN,MULTIPLAN, 790.20,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24778,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,MULTIPLAN,MULTIPLAN, 877.50,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24779,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,MULTIPLAN,MULTIPLAN, 877.50,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24780,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,MULTIPLAN,MULTIPLAN, 122.40,,OUTPCT LIMIT, 87.16,OTHER, 58.48, 133.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24781,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,MULTIPLAN,MULTIPLAN, 57.60,,OUTPCT LIMIT, 41.02,OTHER, 27.52, 62.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24782,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,MULTIPLAN,MULTIPLAN, 67.50,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24783,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,MULTIPLAN,MULTIPLAN, 2696.40,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24784,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,MULTIPLAN,MULTIPLAN, 2696.40,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24785,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,MULTIPLAN,MULTIPLAN, 2934.90,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24786,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,MULTIPLAN,MULTIPLAN, 2934.90,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24787,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MULTIPLAN,MULTIPLAN, 2070.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24788,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MULTIPLAN,MULTIPLAN, 2070.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24789,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,MULTIPLAN,MULTIPLAN, 2070.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24790,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MULTIPLAN,MULTIPLAN, 1800.00,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24791,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,MULTIPLAN,MULTIPLAN, 1800.00,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24792,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,MULTIPLAN,MULTIPLAN, 1800.00,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24793,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,MULTIPLAN,MULTIPLAN, 1800.00,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24794,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,MULTIPLAN,MULTIPLAN, 17.23,,OUTPCT LIMIT, 9.74,OTHER, 1.66, 18.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24795,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,MULTIPLAN,MULTIPLAN, 101.39,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24796,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,MULTIPLAN,MULTIPLAN, 5.40,,OUTPCT LIMIT, 11.82,OTHER, 2.58, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24797,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,MULTIPLAN,MULTIPLAN, 81.09,,OUTPCT LIMIT, 57.75,OTHER, 38.74, 88.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24798,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,MULTIPLAN,MULTIPLAN, 42.08,,OUTPCT LIMIT, 29.96,OTHER, 20.10, 45.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24799,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,MULTIPLAN,MULTIPLAN, 148.78,,OUTPCT LIMIT, 88.75,OTHER, 33.71, 162.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24800,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,MULTIPLAN,MULTIPLAN, 93.60,,OUTPCT LIMIT, 58.81,OTHER, 33.71, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24801,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,MULTIPLAN,MULTIPLAN, 351.90,,OUTPCT LIMIT, 250.60,OTHER, 168.13, 383.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24802,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,MULTIPLAN,MULTIPLAN, 354.96,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24803,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,MULTIPLAN,MULTIPLAN, 354.96,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24804,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,MULTIPLAN,MULTIPLAN, 38.25,,OUTPCT LIMIT, 35.44,OTHER, 18.28, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24805,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,MULTIPLAN,MULTIPLAN, 55.08,,OUTPCT LIMIT, 44.57,OTHER, 26.32, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24806,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,MULTIPLAN,MULTIPLAN, 61.20,,OUTPCT LIMIT, 43.58,OTHER, 29.24, 66.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24807,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24808,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,MULTIPLAN,MULTIPLAN, 233.82,,OUTPCT LIMIT, 166.51,OTHER, 111.71, 254.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24809,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,MULTIPLAN,MULTIPLAN, 84.39,,OUTPCT LIMIT, 60.10,OTHER, 40.32, 91.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24810,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,MULTIPLAN,MULTIPLAN, 6.91,,OUTPCT LIMIT, 4.92,OTHER, 3.30, 7.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24811,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,MULTIPLAN,MULTIPLAN, 6.70,,OUTPCT LIMIT, 4.77,OTHER, 3.20, 7.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24812,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,MULTIPLAN,MULTIPLAN, 18.29,,OUTPCT LIMIT, 13.02,OTHER, 8.74, 19.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24813,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,MULTIPLAN,MULTIPLAN, 189.00,,OUTPCT LIMIT, 134.59,OTHER, 90.30, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24814,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,MULTIPLAN,MULTIPLAN, 1.91,,OUTPCT LIMIT, 1.36,OTHER, .91, 2.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24815,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,MULTIPLAN,MULTIPLAN, 2.95,,OUTPCT LIMIT, 2.10,OTHER, 1.41, 3.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24816,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,MULTIPLAN,MULTIPLAN, 36.39,,OUTPCT LIMIT, 25.91,OTHER, 17.38, 39.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24817,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,MULTIPLAN,MULTIPLAN, 130.60,,OUTPCT LIMIT, 93.00,OTHER, 62.40, 142.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24818,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,MULTIPLAN,MULTIPLAN, 2.05,,OUTPCT LIMIT, 1.46,OTHER, .98, 2.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24819,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,MULTIPLAN,MULTIPLAN, 1.44,,OUTPCT LIMIT, 1.03,OTHER, .69, 1.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24820,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,MULTIPLAN,MULTIPLAN, 7.24,,OUTPCT LIMIT, 5.15,OTHER, 3.46, 7.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24821,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,MULTIPLAN,MULTIPLAN, 16.09,,OUTPCT LIMIT, 11.46,OTHER, 7.69, 17.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24822,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,MULTIPLAN,MULTIPLAN, 6.16,,OUTPCT LIMIT, 4.38,OTHER, 2.94, 6.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24823,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,MULTIPLAN,MULTIPLAN, 3.60,,OUTPCT LIMIT, 2.56,OTHER, 1.72, 3.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24824,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,MULTIPLAN,MULTIPLAN, 10.51,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24825,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,MULTIPLAN,MULTIPLAN, 11.70,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24826,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,MULTIPLAN,MULTIPLAN, 61.49,,OUTPCT LIMIT, 43.79,OTHER, 29.38, 66.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24827,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,MULTIPLAN,MULTIPLAN, 32.33,,OUTPCT LIMIT, 23.02,OTHER, 15.45, 35.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24828,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,MULTIPLAN,MULTIPLAN, 9.47,,OUTPCT LIMIT, 6.74,OTHER, 4.52, 10.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24829,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,MULTIPLAN,MULTIPLAN, 7.31,,OUTPCT LIMIT, 5.20,OTHER, 3.49, 7.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24830,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,MULTIPLAN,MULTIPLAN, 359.10,,OUTPCT LIMIT, 575.18,OTHER, 171.57, 1597.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24831,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,MULTIPLAN,MULTIPLAN, 359.10,,OUTPCT LIMIT, 690.66,OTHER, 171.57, 2082.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24832,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,MULTIPLAN,MULTIPLAN, 359.10,,OUTPCT LIMIT, 656.15,OTHER, 171.57, 1937.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24833,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,MULTIPLAN,MULTIPLAN, 359.10,,OUTPCT LIMIT, 607.70,OTHER, 171.57, 1734.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24834,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,MULTIPLAN,MULTIPLAN, 449.10,,OUTPCT LIMIT, 735.35,OTHER, 214.57, 2065.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24835,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,MULTIPLAN,MULTIPLAN, 769.50,,OUTPCT LIMIT, 421.89,OTHER, 18.42, 837.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24836,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,MULTIPLAN,MULTIPLAN, 4.32,,OUTPCT LIMIT, 3.08,OTHER, 2.06, 4.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24837,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,MULTIPLAN,MULTIPLAN, 313.20,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24838,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,MULTIPLAN,MULTIPLAN, 313.20,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24839,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,MULTIPLAN,MULTIPLAN, 313.20,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24840,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,MULTIPLAN,MULTIPLAN, 313.20,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24841,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,MULTIPLAN,MULTIPLAN, 313.20,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24842,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,MULTIPLAN,MULTIPLAN, 313.20,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24843,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,MULTIPLAN,MULTIPLAN, 313.20,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24844,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,MULTIPLAN,MULTIPLAN, 313.20,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24845,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,MULTIPLAN,MULTIPLAN, 313.20,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24846,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,MULTIPLAN,MULTIPLAN, 313.20,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24847,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,MULTIPLAN,MULTIPLAN, 313.20,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24848,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,MULTIPLAN,MULTIPLAN, 313.20,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24849,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,MULTIPLAN,MULTIPLAN, 373.50,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24850,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,MULTIPLAN,MULTIPLAN, 373.50,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24851,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,MULTIPLAN,MULTIPLAN, 373.50,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24852,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,MULTIPLAN,MULTIPLAN, 373.50,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24853,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24854,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24855,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24856,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24857,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24858,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24859,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24860,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24861,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24862,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24863,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24864,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24865,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24866,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24867,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24868,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24869,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24870,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24871,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24872,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,MULTIPLAN,MULTIPLAN, 1193.40,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24873,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,MULTIPLAN,MULTIPLAN, 95.63,,OUTPCT LIMIT, 62.01,OTHER, 42.53, 104.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24874,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,MULTIPLAN,MULTIPLAN, 102.60,,OUTPCT LIMIT, 73.06,OTHER, 49.02, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24875,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,MULTIPLAN,MULTIPLAN, 90.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24876,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,MULTIPLAN,MULTIPLAN, 450.00,,OUTPCT LIMIT, 320.46,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24877,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,MULTIPLAN,MULTIPLAN, 37.80,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24878,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,MULTIPLAN,MULTIPLAN, 2.70,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24879,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,MULTIPLAN,MULTIPLAN, 31.50,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24880,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,MULTIPLAN,MULTIPLAN, 2.70,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24881,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,MULTIPLAN,MULTIPLAN, 24.30,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24882,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,MULTIPLAN,MULTIPLAN, 2.70,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24883,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,MULTIPLAN,MULTIPLAN, 13.50,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24884,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,MULTIPLAN,MULTIPLAN, 2.84,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24885,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,MULTIPLAN,MULTIPLAN, 67.50,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24886,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,MULTIPLAN,MULTIPLAN, 2.84,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24887,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,MULTIPLAN,MULTIPLAN, 4.07,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24888,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,MULTIPLAN,MULTIPLAN, 90.90,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24889,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,MULTIPLAN,MULTIPLAN, 5.40,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24890,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,MULTIPLAN,MULTIPLAN, 5.40,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24891,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,MULTIPLAN,MULTIPLAN, 165.53,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24892,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,MULTIPLAN,MULTIPLAN, 5.40,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24893,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,MULTIPLAN,MULTIPLAN, 162.00,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24894,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,MULTIPLAN,MULTIPLAN, 52.20,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24895,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,MULTIPLAN,MULTIPLAN, 52.20,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24896,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,MULTIPLAN,MULTIPLAN, 298.94,,OUTPCT LIMIT, 212.89,OTHER, 142.83, 325.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24897,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,MULTIPLAN,MULTIPLAN, 109.61,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24898,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,MULTIPLAN,MULTIPLAN, 67.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24899,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,MULTIPLAN,MULTIPLAN, 886.17,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24900,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,MULTIPLAN,MULTIPLAN, 645.34,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24901,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,MULTIPLAN,MULTIPLAN, 8.10,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24902,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,MULTIPLAN,MULTIPLAN, 5.40,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24903,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,MULTIPLAN,MULTIPLAN, 90.90,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24904,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,MULTIPLAN,MULTIPLAN, 90.90,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24905,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,MULTIPLAN,MULTIPLAN, 90.90,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24906,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,MULTIPLAN,MULTIPLAN, 90.90,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24907,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,MULTIPLAN,MULTIPLAN, 90.90,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24908,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,MULTIPLAN,MULTIPLAN, 90.90,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24909,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,MULTIPLAN,MULTIPLAN, 90.90,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24910,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,MULTIPLAN,MULTIPLAN, 5.40,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24911,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,MULTIPLAN,MULTIPLAN, 90.90,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24912,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,MULTIPLAN,MULTIPLAN, 91.80,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24913,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,MULTIPLAN,MULTIPLAN, 64.66,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24914,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,MULTIPLAN,MULTIPLAN, 64.66,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24915,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,MULTIPLAN,MULTIPLAN, 67.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24916,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,MULTIPLAN,MULTIPLAN, 123.82,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24917,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,MULTIPLAN,MULTIPLAN, 2.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24918,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,MULTIPLAN,MULTIPLAN, 13.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24919,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,MULTIPLAN,MULTIPLAN, 13.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24920,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,MULTIPLAN,MULTIPLAN, 13.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24921,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,MULTIPLAN,MULTIPLAN, 16.20,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24922,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,MULTIPLAN,MULTIPLAN, 21.60,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24923,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,MULTIPLAN,MULTIPLAN, 2.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24924,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,MULTIPLAN,MULTIPLAN, 25.67,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24925,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,MULTIPLAN,MULTIPLAN, 25.67,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24926,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,MULTIPLAN,MULTIPLAN, 27.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24927,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,MULTIPLAN,MULTIPLAN, 27.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24928,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,MULTIPLAN,MULTIPLAN, 27.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24929,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,MULTIPLAN,MULTIPLAN, 27.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24930,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,MULTIPLAN,MULTIPLAN, 2.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24931,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,MULTIPLAN,MULTIPLAN, 2.69,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24932,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,MULTIPLAN,MULTIPLAN, 41.84,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24933,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,MULTIPLAN,MULTIPLAN, 9.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24934,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,MULTIPLAN,MULTIPLAN, 2.84,,OUTPCT LIMIT, 2.02,OTHER, 1.35, 3.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24935,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,MULTIPLAN,MULTIPLAN, 450.90,,OUTPCT LIMIT, 321.10,OTHER, 215.43, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24936,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,MULTIPLAN,MULTIPLAN, 514.80,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24937,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24938,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24939,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24940,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24941,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24942,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24943,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24944,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,MULTIPLAN,MULTIPLAN, 30.63,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24945,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,MULTIPLAN,MULTIPLAN, 136.97,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24946,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,MULTIPLAN,MULTIPLAN, 128.38,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24947,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,MULTIPLAN,MULTIPLAN, 83.87,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24948,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,MULTIPLAN,MULTIPLAN, 76.99,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24949,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,MULTIPLAN,MULTIPLAN, 234.26,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24950,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,MULTIPLAN,MULTIPLAN, 6845.13,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24951,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,MULTIPLAN,MULTIPLAN, 40.70,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24952,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,MULTIPLAN,MULTIPLAN, 1602.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24953,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,MULTIPLAN,MULTIPLAN, 1602.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24954,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,MULTIPLAN,MULTIPLAN, 1602.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24955,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,MULTIPLAN,MULTIPLAN, 1602.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24956,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,MULTIPLAN,MULTIPLAN, 1602.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24957,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,MULTIPLAN,MULTIPLAN, 1602.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24958,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,MULTIPLAN,MULTIPLAN, 2160.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24959,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,MULTIPLAN,MULTIPLAN, 1602.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24960,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,MULTIPLAN,MULTIPLAN, 1602.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24961,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,MULTIPLAN,MULTIPLAN, 1602.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24962,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,MULTIPLAN,MULTIPLAN, 1602.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24963,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,MULTIPLAN,MULTIPLAN, 1602.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24964,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,MULTIPLAN,MULTIPLAN, 1602.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24965,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,MULTIPLAN,MULTIPLAN, 1260.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24966,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,MULTIPLAN,MULTIPLAN, 1260.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24967,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,MULTIPLAN,MULTIPLAN, 1260.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24968,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24969,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24970,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24971,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,MULTIPLAN,MULTIPLAN, 94.50,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24972,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24973,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,MULTIPLAN,MULTIPLAN, 60.42,,OUTPCT LIMIT, 43.03,OTHER, 28.87, 65.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24974,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,MULTIPLAN,MULTIPLAN, 9.00,,OUTPCT LIMIT, 6.41,OTHER, 4.30, 9.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24975,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,MULTIPLAN,MULTIPLAN, 5220.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24976,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,MULTIPLAN,MULTIPLAN, 4320.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24977,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,MULTIPLAN,MULTIPLAN, 4320.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24978,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,MULTIPLAN,MULTIPLAN, 4320.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24979,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24980,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24981,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,MULTIPLAN,MULTIPLAN, 392.40,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24982,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,MULTIPLAN,MULTIPLAN, 264.80,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24983,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,MULTIPLAN,MULTIPLAN, 272.98,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24984,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,MULTIPLAN,MULTIPLAN, 222.40,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24985,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,MULTIPLAN,MULTIPLAN, 247.10,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24986,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,MULTIPLAN,MULTIPLAN, 510.30,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24987,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,MULTIPLAN,MULTIPLAN, 156.06,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24988,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,MULTIPLAN,MULTIPLAN, 90.90,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24989,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,MULTIPLAN,MULTIPLAN, 91.49,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24990,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,MULTIPLAN,MULTIPLAN, 133.88,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24991,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,MULTIPLAN,MULTIPLAN, 15.30,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24992,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,MULTIPLAN,MULTIPLAN, 25.20,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24993,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24994,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24995,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24996,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24997,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24998,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 24999,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25000,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25001,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25002,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25003,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25004,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25005,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,MULTIPLAN,MULTIPLAN, 292.50,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25006,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,MULTIPLAN,MULTIPLAN, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25007,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 920.00,,OUTPCT LIMIT, 920.20,OTHER, 507.84, 1127.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25008,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 680.00,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25009,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1100.00,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25010,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25011,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25012,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25013,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25014,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25015,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25016,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25017,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25018,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25019,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25020,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25021,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25022,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25023,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25024,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25025,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 389.44,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25026,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 389.44,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25027,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 221.00,,OUTPCT LIMIT, 168.89,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25028,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 187.20,,OUTPCT LIMIT, 171.36,OTHER, 103.33, 229.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25029,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 392.98,,OUTPCT LIMIT, 273.87,OTHER, 142.76, 481.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25030,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 351.20,,OUTPCT LIMIT, 276.81,OTHER, 142.76, 430.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25031,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 289.68,,OUTPCT LIMIT, 242.16,OTHER, 155.70, 354.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25032,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 368.80,,OUTPCT LIMIT, 850.02,OTHER, 203.58, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25033,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 351.20,,OUTPCT LIMIT, 667.92,OTHER, 193.86, 1237.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25034,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 123.20,,OUTPCT LIMIT, 177.23,OTHER, 68.01, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25035,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 56.00,,OUTPCT LIMIT, 131.69,OTHER, 30.91, 267.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25036,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 101.60,,OUTPCT LIMIT, 116.49,OTHER, 56.08, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25037,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 488.00,,OUTPCT LIMIT, 405.48,OTHER, 256.74, 597.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25038,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 293.60,,OUTPCT LIMIT, 293.67,OTHER, 162.07, 359.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25039,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 194.40,,OUTPCT LIMIT, 216.69,OTHER, 107.31, 256.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25040,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 61.60,,OUTPCT LIMIT, 61.61,OTHER, 34.00, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25041,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 109.60,,OUTPCT LIMIT, 233.68,OTHER, 60.50, 456.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25042,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 167.20,,OUTPCT LIMIT, 158.67,OTHER, 92.29, 204.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25043,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 127.20,,OUTPCT LIMIT, 112.58,OTHER, 70.21, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25044,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 147.20,,OUTPCT LIMIT, 125.44,OTHER, 81.25, 180.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25045,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 93.60,,OUTPCT LIMIT, 114.17,OTHER, 51.67, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25046,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 110.40,,OUTPCT LIMIT, 122.15,OTHER, 60.94, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25047,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 168.00,,OUTPCT LIMIT, 138.81,OTHER, 86.20, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25048,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 134.40,,OUTPCT LIMIT, 117.21,OTHER, 74.19, 164.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25049,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 164.00,,OUTPCT LIMIT, 258.26,OTHER, 90.53, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25050,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 209.60,,OUTPCT LIMIT, 287.58,OTHER, 115.70, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25051,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 282.40,,OUTPCT LIMIT, 334.39,OTHER, 155.88, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25052,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1908.80,,OUTPCT LIMIT, 1514.68,OTHER, 804.50, 2338.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25053,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1078.40,,OUTPCT LIMIT, 1306.30,OTHER, 595.28, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25054,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 486.40,,OUTPCT LIMIT, 925.64,OTHER, 268.49, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25055,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 159.20,,OUTPCT LIMIT, 389.69,OTHER, 87.88, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25056,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 217.60,,OUTPCT LIMIT, 427.24,OTHER, 120.12, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25057,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 264.80,,OUTPCT LIMIT, 457.59,OTHER, 146.17, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25058,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 186.40,,OUTPCT LIMIT, 732.74,OTHER, 102.89, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25059,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 543.20,,OUTPCT LIMIT, 1168.49,OTHER, 299.85, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25060,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 229.60,,OUTPCT LIMIT, 300.44,OTHER, 126.74, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25061,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 323.20,,OUTPCT LIMIT, 495.14,OTHER, 178.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25062,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 384.80,,OUTPCT LIMIT, 534.75,OTHER, 212.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25063,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 444.00,,OUTPCT LIMIT, 572.81,OTHER, 245.09, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25064,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 396.00,,OUTPCT LIMIT, 541.95,OTHER, 218.59, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25065,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 453.60,,OUTPCT LIMIT, 578.99,OTHER, 250.39, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25066,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1388.80,,OUTPCT LIMIT, 1505.88,OTHER, 766.62, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25067,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 559.20,,OUTPCT LIMIT, 646.89,OTHER, 308.68, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25068,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 658.40,,OUTPCT LIMIT, 1242.56,OTHER, 363.44, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25069,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 351.20,,OUTPCT LIMIT, 513.14,OTHER, 193.86, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25070,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 363.20,,OUTPCT LIMIT, 520.86,OTHER, 200.49, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25071,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 633.60,,OUTPCT LIMIT, 694.73,OTHER, 349.75, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25072,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 520.80,,OUTPCT LIMIT, 947.76,OTHER, 287.48, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25073,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 892.80,,OUTPCT LIMIT, 1393.28,OTHER, 492.83, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25074,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 44.80,,OUTPCT LIMIT, 56.01,OTHER, 24.73, 76.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25075,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 270.32,,OUTPCT LIMIT, 185.53,OTHER, 86.20, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25076,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 103.42,,OUTPCT LIMIT, 97.29,OTHER, 57.09, 126.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25077,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 103.20,,OUTPCT LIMIT, 97.14,OTHER, 56.97, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25078,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 40.80,,OUTPCT LIMIT, 57.02,OTHER, 22.52, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25079,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 342.40,,OUTPCT LIMIT, 372.97,OTHER, 189.00, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25080,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 976.00,,OUTPCT LIMIT, 1446.78,OTHER, 538.75, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25081,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 470.40,,OUTPCT LIMIT, 1121.68,OTHER, 259.66, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25082,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 306.99,,OUTPCT LIMIT, 278.63,OTHER, 165.01, 383.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25083,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 551.07,,OUTPCT LIMIT, 427.61,OTHER, 296.20, 675.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25084,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 333.48,,OUTPCT LIMIT, 237.66,OTHER, 143.26, 408.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25085,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 359.68,,OUTPCT LIMIT, 253.66,OTHER, 143.26, 440.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25086,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 390.00,,OUTPCT LIMIT, 272.17,OTHER, 143.26, 477.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25087,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 355.98,,OUTPCT LIMIT, 251.39,OTHER, 143.26, 436.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25088,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 327.20,,OUTPCT LIMIT, 261.55,OTHER, 143.26, 400.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25089,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 377.54,,OUTPCT LIMIT, 264.56,OTHER, 143.26, 462.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25090,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 381.36,,OUTPCT LIMIT, 306.35,OTHER, 204.98, 467.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25091,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 680.80,,OUTPCT LIMIT, 548.12,OTHER, 309.01, 833.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25092,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 393.60,,OUTPCT LIMIT, 300.52,OTHER, 132.82, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25093,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 428.34,,OUTPCT LIMIT, 293.08,OTHER, 132.82, 524.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25094,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1556.69,,OUTPCT LIMIT, 1023.77,OTHER, 309.01, 1906.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25095,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 603.20,,OUTPCT LIMIT, 498.22,OTHER, 309.01, 738.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25096,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2621.01,,OUTPCT LIMIT, 1703.49,OTHER, 435.32, 3210.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25097,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 693.60,,OUTPCT LIMIT, 601.46,OTHER, 382.87, 849.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25098,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2162.40,,OUTPCT LIMIT, 2228.68,OTHER, 1193.64, 2648.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25099,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2348.80,,OUTPCT LIMIT, 2329.49,OTHER, 1296.54, 2877.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25100,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 102.40,,OUTPCT LIMIT, 163.86,OTHER, 56.52, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25101,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 270.32,,OUTPCT LIMIT, 200.99,OTHER, 145.30, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25102,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 96.80,,OUTPCT LIMIT, 93.03,OTHER, 53.43, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25103,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 10.40,,OUTPCT LIMIT, 22.22,OTHER, 5.74, 43.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25104,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 265.60,,OUTPCT LIMIT, 224.77,OTHER, 146.61, 325.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25105,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 140.80,,OUTPCT LIMIT, 251.63,OTHER, 77.72, 451.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25106,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 437.60,,OUTPCT LIMIT, 1148.36,OTHER, 241.56, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25107,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1037.60,,OUTPCT LIMIT, 1534.16,OTHER, 572.76, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25108,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 221.60,,OUTPCT LIMIT, 232.01,OTHER, 122.32, 271.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25109,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 106.08,,OUTPCT LIMIT, 124.43,OTHER, 57.02, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25110,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 99.20,,OUTPCT LIMIT, 120.23,OTHER, 53.32, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25111,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 115.60,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25112,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 115.60,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25113,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 6820.80,,OUTPCT LIMIT, 5204.99,OTHER, 2293.79, 8355.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25114,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 497.60,,OUTPCT LIMIT, 932.84,OTHER, 274.68, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25115,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 632.16,,OUTPCT LIMIT, 424.57,OTHER, 162.56, 774.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25116,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 485.24,,OUTPCT LIMIT, 334.89,OTHER, 162.56, 594.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25117,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 923.86,,OUTPCT LIMIT, 675.88,OTHER, 470.23, 1131.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25118,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 755.36,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25119,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 755.36,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25120,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 276.84,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25121,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 276.84,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25122,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 249.18,,OUTPCT LIMIT, 176.70,OTHER, 103.34, 305.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25123,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 903.96,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25124,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 903.96,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25125,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1572.75,,OUTPCT LIMIT, 1089.64,OTHER, 544.52, 1926.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25126,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 28.00,,OUTPCT LIMIT, 22.43,OTHER, 15.05, 34.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25127,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 24.84,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25128,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 24.84,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25129,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 24.84,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25130,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 24.84,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25131,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 24.84,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25132,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 24.84,,OUTPCT LIMIT, 20.38,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25133,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 20.00,,OUTPCT LIMIT, 16.02,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25134,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 819.29,,OUTPCT LIMIT, 579.04,OTHER, 331.58, 1003.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25135,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1764.80,,OUTPCT LIMIT, 1525.88,OTHER, 974.17, 2161.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25136,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 4992.00,,OUTPCT LIMIT, 4097.24,OTHER, 2484.68, 6115.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25137,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 5309.60,,OUTPCT LIMIT, 4480.28,OTHER, 2930.90, 6504.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25138,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 656.80,,OUTPCT LIMIT, 813.44,OTHER, 362.55, 1095.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25139,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 5753.60,,OUTPCT LIMIT, 4090.68,OTHER, 1095.12, 7048.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25140,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 193.27,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25141,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 193.27,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25142,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 505.60,,OUTPCT LIMIT, 1187.28,OTHER, 279.09, 2414.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25143,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 312.80,,OUTPCT LIMIT, 803.17,OTHER, 172.67, 1685.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25144,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1759.20,,OUTPCT LIMIT, 1733.21,OTHER, 971.08, 2155.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25145,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2257.60,,OUTPCT LIMIT, 1757.99,OTHER, 857.80, 2765.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25146,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 266.40,,OUTPCT LIMIT, 477.65,OTHER, 147.05, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25147,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 297.60,,OUTPCT LIMIT, 497.71,OTHER, 164.28, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25148,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1879.20,,OUTPCT LIMIT, 1514.68,OTHER, 857.80, 2302.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25149,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2655.20,,OUTPCT LIMIT, 2013.65,OTHER, 857.80, 3252.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25150,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 378.40,,OUTPCT LIMIT, 549.67,OTHER, 208.88, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25151,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 423.20,,OUTPCT LIMIT, 578.48,OTHER, 233.61, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25152,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2204.80,,OUTPCT LIMIT, 2205.29,OTHER, 1217.05, 2700.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25153,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2700.00,,OUTPCT LIMIT, 2700.60,OTHER, 1490.40, 3307.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25154,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 932.98,,OUTPCT LIMIT, 718.33,OTHER, 501.48, 1142.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25155,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2436.80,,OUTPCT LIMIT, 2437.34,OTHER, 1345.11, 2985.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25156,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1288.80,,OUTPCT LIMIT, 1780.93,OTHER, 711.42, 2666.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25157,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1199.20,,OUTPCT LIMIT, 2411.76,OTHER, 661.96, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25158,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 126.40,,OUTPCT LIMIT, 283.55,OTHER, 69.77, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25159,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 150.40,,OUTPCT LIMIT, 298.98,OTHER, 83.02, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25160,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 247.20,,OUTPCT LIMIT, 482.77,OTHER, 136.45, 906.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25161,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 443.20,,OUTPCT LIMIT, 603.90,OTHER, 244.65, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25162,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 519.20,,OUTPCT LIMIT, 652.77,OTHER, 286.60, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25163,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 676.80,,OUTPCT LIMIT, 754.11,OTHER, 373.59, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25164,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 617.60,,OUTPCT LIMIT, 716.04,OTHER, 340.92, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25165,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 595.20,,OUTPCT LIMIT, 701.64,OTHER, 328.55, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25166,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3042.40,,OUTPCT LIMIT, 2366.55,OTHER, 1148.80, 3726.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25167,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 200.80,,OUTPCT LIMIT, 623.49,OTHER, 110.84, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25168,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 288.80,,OUTPCT LIMIT, 256.43,OTHER, 159.42, 353.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25169,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 222.40,,OUTPCT LIMIT, 637.38,OTHER, 122.76, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25170,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 222.40,,OUTPCT LIMIT, 982.61,OTHER, 122.76, 2350.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25171,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1185.60,,OUTPCT LIMIT, 1507.20,OTHER, 654.45, 2085.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25172,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2994.40,,OUTPCT LIMIT, 3143.54,OTHER, 1652.91, 3668.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25173,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1315.20,,OUTPCT LIMIT, 2486.35,OTHER, 725.99, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25174,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1429.60,,OUTPCT LIMIT, 2559.90,OTHER, 789.14, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25175,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1424.80,,OUTPCT LIMIT, 1425.12,OTHER, 786.49, 1745.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25176,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2292.80,,OUTPCT LIMIT, 1667.02,OTHER, 539.71, 2808.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25177,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1036.80,,OUTPCT LIMIT, 1786.42,OTHER, 572.31, 3135.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25178,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2833.60,,OUTPCT LIMIT, 3662.54,OTHER, 1564.15, 5153.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25179,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 292.80,,OUTPCT LIMIT, 889.66,OTHER, 161.63, 1963.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25180,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 322.36,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25181,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 322.36,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25182,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2179.20,,OUTPCT LIMIT, 2146.09,OTHER, 1202.92, 2669.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25183,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 199.77,OTHER, 96.75, 377.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25184,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 266.50,OTHER, 96.75, 657.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25185,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2750.40,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25186,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2750.40,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25187,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 898.28,,OUTPCT LIMIT, 719.65,OTHER, 482.83, 1100.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25188,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1606.84,,OUTPCT LIMIT, 1287.31,OTHER, 863.68, 1968.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25189,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 363.12,,OUTPCT LIMIT, 290.91,OTHER, 195.18, 444.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25190,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1355.20,,OUTPCT LIMIT, 2579.17,OTHER, 748.07, 4781.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25191,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 208.90,,OUTPCT LIMIT, 162.43,OTHER, 112.28, 255.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25192,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.86,,OUTPCT LIMIT, 145.32,OTHER, 97.21, 221.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25193,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 115.52,,OUTPCT LIMIT, 116.13,OTHER, 62.09, 191.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25194,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 95.20,,OUTPCT LIMIT, 76.24,OTHER, 51.17, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25195,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 170.45,,OUTPCT LIMIT, 124.60,OTHER, 86.34, 208.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25196,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25197,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.80,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25198,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25199,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 109.60,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25200,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25201,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 210.61,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25202,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25203,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.80,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25204,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25205,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 227.82,,OUTPCT LIMIT, 171.96,OTHER, 122.45, 279.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25206,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25207,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 175.60,,OUTPCT LIMIT, 127.74,OTHER, 86.34, 215.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25208,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25209,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 256.69,,OUTPCT LIMIT, 189.58,OTHER, 137.97, 314.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25210,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25211,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 157.86,,OUTPCT LIMIT, 116.92,OTHER, 84.85, 193.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25212,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25213,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 436.82,,OUTPCT LIMIT, 299.54,OTHER, 138.19, 535.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25214,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25215,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 308.22,,OUTPCT LIMIT, 221.04,OTHER, 138.19, 377.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25216,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25217,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 236.80,,OUTPCT LIMIT, 177.44,OTHER, 127.28, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25218,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25219,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 82.98,,OUTPCT LIMIT, 71.21,OTHER, 44.60, 101.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25220,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25221,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 283.42,,OUTPCT LIMIT, 193.56,OTHER, 86.34, 347.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25222,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25223,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 332.48,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25224,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2342.51,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25225,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1741.18,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25226,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25227,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25228,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1790.88,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25229,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1790.88,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25230,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25231,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25232,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2342.51,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25233,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2342.51,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25234,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25235,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25236,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1454.18,,OUTPCT LIMIT, 955.20,OTHER, 283.82, 1781.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25237,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25238,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 964.05,,OUTPCT LIMIT, 691.35,OTHER, 432.18, 1180.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25239,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25240,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1264.00,,OUTPCT LIMIT, 887.08,OTHER, 485.27, 1548.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25241,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25242,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1365.60,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25243,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1365.90,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25244,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25245,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25246,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1561.34,,OUTPCT LIMIT, 1055.93,OTHER, 432.18, 1912.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25247,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1965.59,,OUTPCT LIMIT, 1302.68,OTHER, 432.18, 2407.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25248,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25249,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25250,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 651.20,,OUTPCT LIMIT, 513.03,OTHER, 350.02, 797.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25251,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25252,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2003.65,,OUTPCT LIMIT, 1290.59,OTHER, 283.82, 2454.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25253,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25254,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2083.76,,OUTPCT LIMIT, 1374.81,OTHER, 432.18, 2552.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25255,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25256,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1884.72,,OUTPCT LIMIT, 1265.96,OTHER, 485.27, 2308.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25257,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25258,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1569.80,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25259,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1569.80,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25260,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1569.80,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25261,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25262,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25263,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25264,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1888.72,,OUTPCT LIMIT, 1270.81,OTHER, 495.38, 2313.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25265,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25266,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2450.94,,OUTPCT LIMIT, 1681.52,OTHER, 779.04, 3002.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25267,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25268,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1808.31,,OUTPCT LIMIT, 1224.87,OTHER, 508.57, 2215.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25269,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25270,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1928.80,,OUTPCT LIMIT, 1324.21,OTHER, 616.91, 2362.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25271,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25272,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2207.60,,OUTPCT LIMIT, 1532.99,OTHER, 779.04, 2704.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25273,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25274,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1822.60,,OUTPCT LIMIT, 1233.59,OTHER, 508.57, 2232.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25275,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25276,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1817.60,,OUTPCT LIMIT, 1256.33,OTHER, 616.91, 2226.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25277,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25278,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2089.80,,OUTPCT LIMIT, 1461.09,OTHER, 779.04, 2560.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25279,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25280,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2117.61,,OUTPCT LIMIT, 1413.66,OTHER, 508.57, 2594.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25281,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25282,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3269.54,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25283,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3269.54,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25284,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25285,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25286,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.80,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25287,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.80,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25288,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.80,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25289,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.80,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25290,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25291,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25292,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25293,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25294,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.80,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25295,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25296,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.80,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25297,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.80,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25298,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25299,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25300,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 362.87,,OUTPCT LIMIT, 242.05,OTHER, 86.34, 444.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25301,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 365.27,,OUTPCT LIMIT, 243.52,OTHER, 86.34, 447.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25302,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25303,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25304,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 296.91,,OUTPCT LIMIT, 214.14,OTHER, 138.19, 363.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25305,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 339.33,,OUTPCT LIMIT, 240.03,OTHER, 138.19, 415.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25306,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25307,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25308,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 353.82,,OUTPCT LIMIT, 248.87,OTHER, 138.19, 433.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25309,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25310,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 236.80,,OUTPCT LIMIT, 165.10,OTHER, 86.34, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25311,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25312,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.80,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25313,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25314,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1873.92,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25315,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1873.92,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25316,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1873.92,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25317,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25318,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25319,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1873.92,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25320,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2234.82,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25321,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25322,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2787.89,,OUTPCT LIMIT, 1817.25,OTHER, 485.27, 3415.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25323,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25324,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1873.92,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25325,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1873.92,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25326,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1873.92,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25327,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25328,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25329,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25330,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3984.02,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25331,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2684.54,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25332,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2684.54,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25333,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2684.54,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25334,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2684.54,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25335,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25336,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25337,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25338,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25339,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1012.80,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25340,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2260.00,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25341,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25342,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25343,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 243.20,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25344,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 243.20,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25345,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25346,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25347,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 351.82,,OUTPCT LIMIT, 247.65,OTHER, 138.19, 430.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25348,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25349,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 520.48,,OUTPCT LIMIT, 350.60,OTHER, 138.19, 637.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25350,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25351,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 572.95,,OUTPCT LIMIT, 382.63,OTHER, 138.19, 701.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25352,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25353,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 426.93,,OUTPCT LIMIT, 293.50,OTHER, 138.19, 522.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25354,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25355,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 381.65,,OUTPCT LIMIT, 265.86,OTHER, 138.19, 467.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25356,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25357,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 210.61,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25358,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25359,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 200.00,,OUTPCT LIMIT, 142.64,OTHER, 86.34, 245.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25360,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25361,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.80,,OUTPCT LIMIT, 63.06,OTHER, 36.98, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25362,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 210.61,,OUTPCT LIMIT, 163.44,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25363,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25364,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 370.80,,OUTPCT LIMIT, 259.24,OTHER, 138.19, 454.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25365,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25366,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 219.54,,OUTPCT LIMIT, 166.91,OTHER, 118.00, 268.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25367,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25368,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 613.02,,OUTPCT LIMIT, 407.08,OTHER, 138.19, 750.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25369,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25370,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2280.17,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25371,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2280.17,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25372,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2280.17,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25373,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25374,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25375,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25376,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 900.00,,OUTPCT LIMIT, 664.89,OTHER, 483.75, 1102.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25377,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25378,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2591.01,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25379,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2591.01,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25380,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25381,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25382,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2560.00,,OUTPCT LIMIT, 1665.51,OTHER, 432.18, 3136.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25383,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25384,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2247.08,,OUTPCT LIMIT, 1439.18,OTHER, 283.82, 2752.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25385,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25386,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2538.83,,OUTPCT LIMIT, 1652.58,OTHER, 432.18, 3110.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25387,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25388,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2400.00,,OUTPCT LIMIT, 1580.48,OTHER, 485.27, 2940.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25389,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25390,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2606.86,,OUTPCT LIMIT, 1712.29,OTHER, 508.57, 3193.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25391,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25392,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2905.82,,OUTPCT LIMIT, 1894.78,OTHER, 508.57, 3559.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25393,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25394,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2550.56,,OUTPCT LIMIT, 1677.93,OTHER, 508.57, 3124.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25395,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25396,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3168.96,,OUTPCT LIMIT, 2119.80,OTHER, 779.04, 3881.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25397,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25398,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3856.62,,OUTPCT LIMIT, 2539.54,OTHER, 779.04, 4724.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25399,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25400,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3611.95,,OUTPCT LIMIT, 2390.20,OTHER, 779.04, 4424.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25401,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25402,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25403,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25404,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25405,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 334.06,,OUTPCT LIMIT, 236.81,OTHER, 138.19, 409.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25406,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25407,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 263.70,,OUTPCT LIMIT, 193.87,OTHER, 138.19, 323.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25408,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25409,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1955.43,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25410,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1955.43,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25411,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25412,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25413,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1889.28,,OUTPCT LIMIT, 1256.10,OTHER, 432.18, 2314.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25414,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25415,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1276.40,,OUTPCT LIMIT, 894.65,OTHER, 485.27, 1563.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25416,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25417,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2671.13,,OUTPCT LIMIT, 1751.53,OTHER, 508.57, 3272.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25418,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25419,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 4003.76,,OUTPCT LIMIT, 2629.35,OTHER, 779.04, 4904.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25420,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25421,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1600.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25422,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1600.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25423,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1600.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25424,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25425,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25426,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25427,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 235.30,,OUTPCT LIMIT, 164.19,OTHER, 86.34, 288.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25428,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25429,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 333.87,,OUTPCT LIMIT, 224.35,OTHER, 86.34, 408.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25430,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25431,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 308.25,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25432,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 308.25,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25433,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 319.72,,OUTPCT LIMIT, 215.71,OTHER, 86.34, 391.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25434,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25435,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25436,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25437,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 210.61,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25438,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 210.61,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25439,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 210.61,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25440,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25441,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25442,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25443,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 254.40,,OUTPCT LIMIT, 175.84,OTHER, 86.34, 311.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25444,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 243.29,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25445,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 243.29,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25446,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25447,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25448,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25449,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 331.20,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25450,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 331.20,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25451,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 339.87,,OUTPCT LIMIT, 240.36,OTHER, 138.19, 416.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25452,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25453,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25454,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25455,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 326.26,,OUTPCT LIMIT, 219.70,OTHER, 86.34, 399.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25456,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 317.66,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25457,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 317.66,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25458,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25459,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25460,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25461,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 304.72,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25462,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 313.32,,OUTPCT LIMIT, 211.81,OTHER, 86.34, 383.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25463,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 304.72,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25464,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25465,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25466,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25467,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 343.20,,OUTPCT LIMIT, 230.04,OTHER, 86.34, 420.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25468,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 332.48,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25469,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25470,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25471,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25472,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 344.48,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25473,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 344.48,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25474,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 355.20,,OUTPCT LIMIT, 237.37,OTHER, 86.34, 435.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25475,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25476,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25477,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25478,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 109.60,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25479,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 152.00,,OUTPCT LIMIT, 125.68,OTHER, 81.70, 186.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25480,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 109.60,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25481,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25482,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25483,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25484,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 316.48,,OUTPCT LIMIT, 213.73,OTHER, 86.34, 387.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25485,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 306.65,,OUTPCT LIMIT, 207.73,OTHER, 86.34, 375.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25486,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 306.66,,OUTPCT LIMIT, 207.74,OTHER, 86.34, 375.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25487,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25488,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25489,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25490,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 356.54,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25491,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 365.14,,OUTPCT LIMIT, 243.44,OTHER, 86.34, 447.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25492,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 356.54,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25493,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25494,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25495,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25496,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 336.80,,OUTPCT LIMIT, 238.48,OTHER, 138.19, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25497,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 326.08,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25498,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 326.08,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25499,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25500,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25501,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25502,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 327.33,,OUTPCT LIMIT, 220.36,OTHER, 86.34, 400.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25503,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 327.43,,OUTPCT LIMIT, 220.42,OTHER, 86.34, 401.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25504,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 336.03,,OUTPCT LIMIT, 225.67,OTHER, 86.34, 411.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25505,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25506,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25507,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25508,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 272.72,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25509,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 252.52,,OUTPCT LIMIT, 174.69,OTHER, 86.34, 309.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25510,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 243.92,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25511,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 243.92,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25512,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 243.92,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25513,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 243.92,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25514,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 243.92,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25515,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 243.92,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25516,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 243.92,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25517,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 243.92,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25518,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 243.92,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25519,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 243.92,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25520,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 243.92,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25521,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25522,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25523,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25524,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25525,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25526,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25527,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25528,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25529,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25530,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25531,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25532,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25533,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25534,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1513.34,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25535,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1627.62,,OUTPCT LIMIT, 1061.06,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25536,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1627.62,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25537,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1627.62,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25538,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1627.62,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25539,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1627.62,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25540,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1627.62,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25541,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 535.20,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25542,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 535.20,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25543,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1627.62,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25544,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1627.62,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25545,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 535.20,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25546,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1627.62,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25547,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1627.62,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25548,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1513.34,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25549,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25550,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25551,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25552,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25553,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25554,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25555,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25556,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25557,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25558,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25559,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25560,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25561,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25562,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25563,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2263.19,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25564,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2263.19,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25565,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25566,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25567,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25568,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1079.20,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25569,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1079.20,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25570,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25571,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25572,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1530.92,,OUTPCT LIMIT, 1055.55,OTHER, 508.57, 1875.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25573,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25574,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2640.20,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25575,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2640.20,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25576,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2640.20,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25577,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25578,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25579,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25580,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2691.74,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25581,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2691.74,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25582,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2691.74,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25583,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2691.74,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25584,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2691.74,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25585,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2691.74,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25586,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2691.74,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25587,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2691.74,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25588,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2691.74,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25589,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2691.74,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25590,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2691.74,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25591,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2691.74,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25592,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2691.74,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25593,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2691.74,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25594,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2691.74,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25595,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2691.74,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25596,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25597,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25598,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25599,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25600,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25601,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25602,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25603,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25604,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25605,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25606,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25607,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25608,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25609,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25610,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25611,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25612,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2072.20,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25613,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2072.20,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25614,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25615,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25616,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25617,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25618,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25619,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25620,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 288.22,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25621,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 288.22,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25622,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 288.22,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25623,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25624,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25625,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25626,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 278.38,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25627,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 278.38,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25628,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 278.38,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25629,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 278.38,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25630,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 278.38,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25631,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25632,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25633,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25634,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25635,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 364.14,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25636,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 289.58,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25637,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25638,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25639,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 298.03,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25640,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 298.03,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25641,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 306.63,,OUTPCT LIMIT, 208.23,OTHER, 88.46, 375.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25642,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25643,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25644,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25645,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 311.55,,OUTPCT LIMIT, 210.73,OTHER, 86.34, 381.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25646,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 301.73,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25647,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 301.73,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25648,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25649,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25650,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25651,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 387.06,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25652,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 395.66,,OUTPCT LIMIT, 274.41,OTHER, 138.19, 484.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25653,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 387.06,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25654,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25655,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25656,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25657,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 604.80,,OUTPCT LIMIT, 402.07,OTHER, 138.19, 740.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25658,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 593.80,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25659,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 593.80,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25660,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25661,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25662,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25663,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 217.58,,OUTPCT LIMIT, 153.37,OTHER, 86.34, 266.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25664,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25665,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 364.54,,OUTPCT LIMIT, 243.07,OTHER, 86.34, 446.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25666,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 355.94,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25667,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 355.94,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25668,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25669,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25670,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25671,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.80,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25672,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.80,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25673,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 137.60,,OUTPCT LIMIT, 116.89,OTHER, 73.96, 168.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25674,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25675,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25676,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25677,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 304.79,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25678,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 304.79,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25679,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 315.20,,OUTPCT LIMIT, 225.30,OTHER, 138.19, 386.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25680,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25681,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25682,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25683,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 344.80,,OUTPCT LIMIT, 243.37,OTHER, 138.19, 422.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25684,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 333.98,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25685,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 333.98,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25686,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25687,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25688,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25689,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 271.97,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25690,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 271.97,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25691,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25692,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25693,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 376.21,,OUTPCT LIMIT, 250.19,OTHER, 86.34, 460.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25694,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 367.45,,OUTPCT LIMIT, 244.84,OTHER, 86.34, 450.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25695,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 367.61,,OUTPCT LIMIT, 244.94,OTHER, 86.34, 450.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25696,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25697,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25698,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25699,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 186.40,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25700,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 186.40,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25701,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 186.40,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25702,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25703,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25704,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25705,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 248.90,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25706,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 248.90,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25707,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 248.90,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25708,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 248.90,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25709,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 248.90,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25710,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 248.90,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25711,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 248.90,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25712,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 248.90,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25713,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 179.26,OTHER, 86.34, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25714,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 248.90,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25715,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 248.90,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25716,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25717,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25718,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25719,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25720,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25721,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25722,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25723,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25724,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25725,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25726,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25727,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1833.56,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25728,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1833.56,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25729,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1833.56,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25730,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1844.00,,OUTPCT LIMIT, 1193.14,OTHER, 283.82, 2258.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25731,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1833.56,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25732,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1833.56,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25733,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1833.56,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25734,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1833.56,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25735,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1833.56,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25736,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1833.56,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25737,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1833.56,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25738,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1833.56,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25739,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1833.56,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25740,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1833.56,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25741,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25742,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25743,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25744,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25745,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25746,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25747,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25748,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25749,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25750,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25751,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25752,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25753,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25754,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25755,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2182.40,,OUTPCT LIMIT, 1435.02,OTHER, 432.18, 2673.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25756,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2171.54,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25757,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2171.54,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25758,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25759,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25760,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25761,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1079.20,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25762,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1079.20,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25763,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1079.20,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25764,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25765,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25766,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25767,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1111.20,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25768,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1111.20,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25769,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25770,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25771,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2367.15,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25772,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2367.15,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25773,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2367.15,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25774,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2367.15,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25775,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2367.15,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25776,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2367.15,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25777,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25778,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25779,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25780,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25781,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25782,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25783,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2896.30,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25784,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2896.30,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25785,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25786,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25787,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2522.98,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25788,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2522.98,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25789,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2522.99,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25790,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2522.99,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25791,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2522.98,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25792,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2522.98,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25793,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2522.98,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25794,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2522.98,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25795,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2522.98,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25796,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2522.98,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25797,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25798,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25799,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25800,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25801,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25802,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25803,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25804,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25805,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25806,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25807,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3682.33,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25808,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3682.33,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25809,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3682.33,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25810,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3682.33,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25811,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3682.33,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25812,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25813,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25814,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25815,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25816,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25817,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1600.00,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25818,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1840.00,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25819,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1840.00,,OUTPCT LIMIT, 1474.10,OTHER, 989.00, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25820,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1464.00,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25821,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1464.00,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25822,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25823,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25824,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25825,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25826,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25827,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 132.80,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25828,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 132.80,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25829,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25830,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25831,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.80,,OUTPCT LIMIT, 83.13,OTHER, 36.98, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25832,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 105.42,OTHER, 37.54, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25833,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 474.34,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25834,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 474.34,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25835,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25836,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25837,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2094.47,,OUTPCT LIMIT, 1346.03,OTHER, 283.82, 2565.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25838,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25839,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2361.30,,OUTPCT LIMIT, 1544.22,OTHER, 432.18, 2892.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25840,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25841,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2666.58,,OUTPCT LIMIT, 1743.20,OTHER, 485.27, 3266.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25842,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25843,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 4784.02,,OUTPCT LIMIT, 3113.75,OTHER, 813.20, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25844,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 284.00,,OUTPCT LIMIT, 473.04,OTHER, 156.77, 813.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25845,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2663.06,,OUTPCT LIMIT, 1743.46,OTHER, 495.38, 3262.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25846,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25847,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 4167.37,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25848,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 4167.37,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25849,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25850,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25851,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 4784.02,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25852,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 4784.02,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25853,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25854,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25855,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 5360.17,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25856,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 5360.17,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25857,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 5360.17,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25858,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25859,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25860,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25861,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2569.80,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25862,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2569.80,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25863,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25864,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25865,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2705.75,,OUTPCT LIMIT, 1837.06,OTHER, 779.04, 3314.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25866,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25867,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2000.00,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25868,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3238.40,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25869,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25870,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25871,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25872,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 558.40,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25873,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 558.40,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25874,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 558.40,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25875,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25876,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25877,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 878.82,,OUTPCT LIMIT, 704.06,OTHER, 472.37, 1076.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25878,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 68.02,OTHER, 37.54, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25879,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 309.12,,OUTPCT LIMIT, 248.14,OTHER, 166.15, 378.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25880,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 230.64,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25881,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 606.86,,OUTPCT LIMIT, 429.88,OTHER, 249.71, 743.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25882,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 132.91,OTHER, 37.54, 249.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25883,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2256.94,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25884,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2256.94,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25885,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25886,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25887,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 280.00,,OUTPCT LIMIT, 224.32,OTHER, 150.50, 343.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25888,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25889,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 576.39,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25890,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 576.39,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25891,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 576.39,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25892,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25893,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25894,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25895,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 434.06,,OUTPCT LIMIT, 286.59,OTHER, 90.89, 531.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25896,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25897,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 409.06,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25898,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 409.06,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25899,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 409.06,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25900,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 420.00,,OUTPCT LIMIT, 288.12,OTHER, 133.37, 514.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25901,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25902,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25903,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25904,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25905,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 769.64,,OUTPCT LIMIT, 503.49,OTHER, 141.55, 942.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25906,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25907,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 702.88,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25908,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 702.88,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25909,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 702.88,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25910,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 702.88,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25911,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 702.88,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25912,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25913,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25914,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25915,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25916,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25917,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 702.88,,OUTPCT LIMIT, 468.07,OTHER, 163.97, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25918,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 200.02,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25919,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 633.92,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25920,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 633.92,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25921,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 633.92,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25922,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 633.92,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25923,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 623.86,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25924,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25925,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25926,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25927,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25928,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25929,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 623.86,,OUTPCT LIMIT, 414.50,OTHER, 141.55, 764.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25930,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25931,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 300.00,,OUTPCT LIMIT, 214.87,OTHER, 133.37, 367.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25932,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 163.37,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25933,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 614.41,,OUTPCT LIMIT, 408.73,OTHER, 141.55, 752.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25934,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25935,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 776.30,,OUTPCT LIMIT, 507.55,OTHER, 141.55, 950.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25936,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25937,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1235.20,,OUTPCT LIMIT, 775.60,OTHER, 90.89, 1513.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25938,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25939,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 424.00,,OUTPCT LIMIT, 290.56,OTHER, 133.37, 519.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25940,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25941,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 632.50,,OUTPCT LIMIT, 419.77,OTHER, 141.55, 774.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25942,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25943,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 717.38,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25944,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 717.38,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25945,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 717.38,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25946,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25947,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25948,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25949,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 500.60,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25950,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 483.94,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25951,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25952,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25953,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 613.98,,OUTPCT LIMIT, 408.48,OTHER, 141.55, 752.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25954,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25955,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1280.00,,OUTPCT LIMIT, 813.95,OTHER, 137.10, 1568.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25956,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 809.31,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25957,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 809.31,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25958,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25959,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25960,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25961,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 287.17,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25962,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 440.00,,OUTPCT LIMIT, 300.33,OTHER, 133.37, 539.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25963,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 287.17,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25964,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 287.17,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25965,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 287.17,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25966,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 287.17,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25967,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 287.17,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25968,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 287.17,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25969,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 287.17,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25970,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25971,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25972,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25973,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25974,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25975,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25976,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25977,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25978,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25979,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 531.91,,OUTPCT LIMIT, 426.14,OTHER, 285.90, 651.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25980,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25981,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 339.67,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25982,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 339.67,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25983,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 339.67,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25984,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 285.60,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25985,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25986,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 285.60,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25987,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 285.60,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25988,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 232.80,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25989,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 232.80,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25990,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 113.60,,OUTPCT LIMIT, 91.01,OTHER, 61.06, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25991,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 148.00,,OUTPCT LIMIT, 78.82,OTHER, 21.15, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25992,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 232.80,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25993,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 232.80,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25994,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 232.80,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25995,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 232.80,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25996,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25997,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25998,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 25999,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26000,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 392.00,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26001,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 327.20,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26002,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 392.00,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26003,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26004,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26005,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 232.80,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26006,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 232.80,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26007,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 232.80,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26008,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 232.80,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26009,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 480.00,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26010,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 332.00,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26011,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 332.00,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26012,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26013,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26014,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26015,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26016,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26017,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26018,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26019,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 136.80,,OUTPCT LIMIT, 116.40,OTHER, 73.53, 167.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26020,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 33.60,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26021,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 587.86,,OUTPCT LIMIT, 414.07,OTHER, 232.03, 720.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26022,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 156.80,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26023,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 280.80,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26024,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 33.60,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26025,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 33.60,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26026,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 236.80,,OUTPCT LIMIT, 154.63,OTHER, 42.36, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26027,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 280.80,,OUTPCT LIMIT, 204.30,OTHER, 138.19, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26028,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 33.60,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26029,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1021.46,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26030,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1021.46,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26031,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26032,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26033,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 794.05,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26034,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 794.05,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26035,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26036,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26037,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1116.73,,OUTPCT LIMIT, 757.92,OTHER, 320.35, 1367.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26038,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 230.15,OTHER, 99.36, 320.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26039,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1348.31,,OUTPCT LIMIT, 899.81,OTHER, 322.62, 1651.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26040,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 230.96,OTHER, 99.36, 322.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26041,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1576.00,,OUTPCT LIMIT, 1092.65,OTHER, 548.80, 1930.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26042,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 311.74,OTHER, 99.36, 548.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26043,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1250.50,,OUTPCT LIMIT, 864.03,OTHER, 423.08, 1531.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26044,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26045,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 400.00,,OUTPCT LIMIT, 344.89,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26046,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26047,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1200.00,,OUTPCT LIMIT, 830.31,OTHER, 410.92, 1470.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26048,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26049,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1648.00,,OUTPCT LIMIT, 1103.77,OTHER, 410.92, 2018.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26050,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26051,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1680.00,,OUTPCT LIMIT, 1111.16,OTHER, 359.95, 2058.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26052,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26053,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 882.00,,OUTPCT LIMIT, 624.07,OTHER, 359.95, 1080.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26054,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26055,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 961.06,,OUTPCT LIMIT, 672.34,OTHER, 360.01, 1177.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26056,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26057,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 776.00,,OUTPCT LIMIT, 559.38,OTHER, 360.01, 950.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26058,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26059,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1871.49,,OUTPCT LIMIT, 1228.06,OTHER, 360.01, 2292.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26060,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26061,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1979.61,,OUTPCT LIMIT, 1294.05,OTHER, 360.01, 2425.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26062,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26063,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 876.00,,OUTPCT LIMIT, 701.80,OTHER, 470.85, 1073.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26064,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 180.04,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26065,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1442.80,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26066,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1442.80,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26067,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26068,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26069,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3275.42,,OUTPCT LIMIT, 2267.81,OTHER, 1127.76, 4012.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26070,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26071,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1161.68,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26072,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1161.68,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26073,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26074,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26075,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 931.00,,OUTPCT LIMIT, 635.79,OTHER, 283.54, 1140.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26076,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 217.00,OTHER, 99.36, 283.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26077,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1495.06,,OUTPCT LIMIT, 984.09,OTHER, 300.36, 1831.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26078,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 223.01,OTHER, 99.36, 300.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26079,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1547.46,,OUTPCT LIMIT, 1050.06,OTHER, 443.12, 1895.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26080,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 274.00,OTHER, 99.36, 443.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26081,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 832.00,,OUTPCT LIMIT, 684.67,OTHER, 447.20, 1019.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26082,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.00,,OUTPCT LIMIT, 380.97,OTHER, 99.36, 742.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26083,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3811.20,,OUTPCT LIMIT, 2685.69,OTHER, 1509.32, 4668.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26084,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 320.00,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26085,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3947.20,,OUTPCT LIMIT, 2768.70,OTHER, 1509.32, 4835.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26086,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 320.00,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26087,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 48.47,,OUTPCT LIMIT, 34.30,OTHER, 19.78, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26088,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 48.47,,OUTPCT LIMIT, 32.49,OTHER, 12.18, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26089,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 497.60,,OUTPCT LIMIT, 398.65,OTHER, 267.46, 609.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26090,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 111.88,,OUTPCT LIMIT, 70.69,OTHER, 10.09, 137.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26091,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 194.20,,OUTPCT LIMIT, 122.16,OTHER, 15.20, 237.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26092,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 152.38,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26093,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 152.38,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26094,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 132.00,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26095,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 132.00,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26096,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 228.58,,OUTPCT LIMIT, 155.85,OTHER, 68.59, 280.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26097,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 124.81,,OUTPCT LIMIT, 78.98,OTHER, 11.76, 152.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26098,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 104.80,,OUTPCT LIMIT, 69.30,OTHER, 22.37, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26099,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 357.60,,OUTPCT LIMIT, 229.30,OTHER, 46.28, 438.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26100,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 141.01,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26101,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 134.08,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26102,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 80.01,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26103,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 80.01,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26104,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 123.74,,OUTPCT LIMIT, 80.17,OTHER, 19.50, 151.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26105,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 77.30,,OUTPCT LIMIT, 54.61,OTHER, 31.20, 94.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26106,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 123.66,,OUTPCT LIMIT, 80.03,OTHER, 19.08, 151.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26107,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 122.26,,OUTPCT LIMIT, 79.17,OTHER, 19.08, 149.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26108,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 101.06,,OUTPCT LIMIT, 63.95,OTHER, 9.52, 123.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26109,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 37.60,,OUTPCT LIMIT, 28.28,OTHER, 20.21, 46.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26110,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 129.66,,OUTPCT LIMIT, 83.69,OTHER, 19.08, 158.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26111,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 79.00,,OUTPCT LIMIT, 53.47,OTHER, 22.03, 96.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26112,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 123.31,,OUTPCT LIMIT, 79.81,OTHER, 19.08, 151.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26113,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 65.42,,OUTPCT LIMIT, 44.64,OTHER, 19.78, 80.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26114,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 231.34,,OUTPCT LIMIT, 145.91,OTHER, 19.78, 283.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26115,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 98.16,,OUTPCT LIMIT, 64.76,OTHER, 20.36, 120.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26116,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 192.10,,OUTPCT LIMIT, 121.34,OTHER, 17.16, 235.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26117,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 131.25,,OUTPCT LIMIT, 84.76,OTHER, 19.50, 160.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26118,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 207.98,,OUTPCT LIMIT, 134.69,OTHER, 32.53, 254.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26119,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 138.46,,OUTPCT LIMIT, 90.91,OTHER, 26.84, 169.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26120,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 152.27,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26121,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 20.00,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26122,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 32.00,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26123,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 32.00,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26124,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 209.50,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26125,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 236.00,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26126,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 135.20,,OUTPCT LIMIT, 108.31,OTHER, 72.67, 165.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26127,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 120.00,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26128,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 60.80,,OUTPCT LIMIT, 48.71,OTHER, 32.68, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26129,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 224.62,,OUTPCT LIMIT, 179.95,OTHER, 120.73, 275.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26130,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 143.08,,OUTPCT LIMIT, 114.63,OTHER, 76.91, 175.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26131,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 32.66,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26132,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 60.00,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26133,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 32.66,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26134,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 32.66,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26135,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 112.80,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26136,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.71,,OUTPCT LIMIT, 67.87,OTHER, 45.53, 103.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26137,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 127.20,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26138,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 127.20,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26139,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 127.20,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26140,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 108.00,,OUTPCT LIMIT, 86.52,OTHER, 58.05, 132.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26141,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.80,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26142,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 232.80,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26143,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 55.37,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26144,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 55.37,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26145,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 55.37,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26146,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 33.03,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26147,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 33.03,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26148,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 33.03,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26149,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 10.40,,OUTPCT LIMIT, 7.12,OTHER, 3.24, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26150,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 12.00,,OUTPCT LIMIT, 8.07,OTHER, 3.12, 14.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26151,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 50.64,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26152,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 50.64,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26153,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 119.20,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26154,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 119.20,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26155,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 197.31,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26156,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 197.31,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26157,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 393.60,,OUTPCT LIMIT, 262.66,OTHER, 94.12, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26158,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 651.31,,OUTPCT LIMIT, 428.98,OTHER, 131.99, 797.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26159,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 161.87,,OUTPCT LIMIT, 129.68,OTHER, 87.01, 198.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26160,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 305.60,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26161,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 305.60,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26162,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.54,,OUTPCT LIMIT, 53.15,OTHER, 6.50, 103.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26163,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 59.15,,OUTPCT LIMIT, 38.90,OTHER, 11.76, 72.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26164,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 218.86,,OUTPCT LIMIT, 146.83,OTHER, 55.61, 268.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26165,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 30.20,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26166,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 30.20,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26167,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 43.00,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26168,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 43.00,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26169,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 96.00,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26170,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 96.00,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26171,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 77.90,,OUTPCT LIMIT, 50.88,OTHER, 13.98, 95.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26172,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 108.87,,OUTPCT LIMIT, 71.06,OTHER, 19.36, 133.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26173,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 171.86,,OUTPCT LIMIT, 109.86,OTHER, 20.82, 210.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26174,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 121.91,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26175,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 121.91,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26176,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 95.20,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26177,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 95.20,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26178,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 79.57,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26179,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 79.57,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26180,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 148.00,,OUTPCT LIMIT, 100.38,OTHER, 42.16, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26181,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 181.67,,OUTPCT LIMIT, 121.92,OTHER, 46.34, 222.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26182,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 70.40,,OUTPCT LIMIT, 50.20,OTHER, 30.37, 86.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26183,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 179.90,,OUTPCT LIMIT, 116.31,OTHER, 27.31, 220.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26184,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 76.00,,OUTPCT LIMIT, 49.78,OTHER, 14.24, 93.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26185,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 94.85,,OUTPCT LIMIT, 63.44,OTHER, 23.30, 116.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26186,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 56.75,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26187,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 56.75,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26188,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 51.36,,OUTPCT LIMIT, 33.07,OTHER, 7.22, 62.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26189,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 29.20,,OUTPCT LIMIT, 19.33,OTHER, 6.31, 35.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26190,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 52.14,,OUTPCT LIMIT, 33.34,OTHER, 6.38, 63.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26191,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 56.73,OTHER, 22.92, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26192,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 186.75,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26193,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 199.20,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26194,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 186.75,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26195,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 187.54,,OUTPCT LIMIT, 123.66,OTHER, 38.58, 229.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26196,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 52.94,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26197,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 52.94,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26198,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 52.94,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26199,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 105.75,,OUTPCT LIMIT, 69.24,OTHER, 19.70, 129.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26200,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 78.47,,OUTPCT LIMIT, 49.97,OTHER, 8.69, 96.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26201,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 65.60,,OUTPCT LIMIT, 44.47,OTHER, 18.58, 80.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26202,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 99.80,,OUTPCT LIMIT, 65.14,OTHER, 17.74, 122.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26203,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 132.29,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26204,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 132.29,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26205,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 87.20,,OUTPCT LIMIT, 59.01,OTHER, 24.29, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26206,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 194.48,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26207,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 196.34,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26208,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 86.46,,OUTPCT LIMIT, 56.46,OTHER, 15.47, 105.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26209,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 19.20,,OUTPCT LIMIT, 13.69,OTHER, 8.28, 23.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26210,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 113.79,,OUTPCT LIMIT, 73.71,OTHER, 17.87, 139.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26211,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 134.34,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26212,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 134.34,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26213,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 99.48,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26214,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 99.48,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26215,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 298.05,,OUTPCT LIMIT, 190.19,OTHER, 34.69, 365.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26216,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 337.09,,OUTPCT LIMIT, 214.01,OTHER, 34.69, 412.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26217,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 74.14,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26218,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 74.14,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26219,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 60.80,,OUTPCT LIMIT, 41.70,OTHER, 19.28, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26220,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 91.36,,OUTPCT LIMIT, 59.73,OTHER, 16.63, 111.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26221,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 48.94,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26222,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 48.94,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26223,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 48.94,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26224,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 61.17,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26225,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 61.17,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26226,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 147.82,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26227,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 147.82,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26228,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 67.20,,OUTPCT LIMIT, 45.06,OTHER, 16.97, 82.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26229,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 121.22,,OUTPCT LIMIT, 76.21,OTHER, 9.31, 148.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26230,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 109.86,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26231,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 109.86,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26232,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 113.06,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26233,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 113.06,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26234,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 194.56,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26235,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 194.56,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26236,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 143.23,,OUTPCT LIMIT, 93.87,OTHER, 27.06, 175.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26237,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 206.27,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26238,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 206.27,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26239,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 119.20,,OUTPCT LIMIT, 83.83,OTHER, 46.51, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26240,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 107.20,,OUTPCT LIMIT, 73.72,OTHER, 34.82, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26241,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 109.60,,OUTPCT LIMIT, 75.45,OTHER, 35.93, 134.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26242,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 186.20,,OUTPCT LIMIT, 121.64,OTHER, 33.53, 228.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26243,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 110.45,,OUTPCT LIMIT, 69.17,OTHER, 7.34, 135.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26244,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 194.81,,OUTPCT LIMIT, 124.67,OTHER, 24.19, 238.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26245,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 117.60,,OUTPCT LIMIT, 76.46,OTHER, 19.63, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26246,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 108.85,,OUTPCT LIMIT, 71.48,OTHER, 21.17, 133.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26247,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 339.01,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26248,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 124.01,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26249,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.61,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26250,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.61,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26251,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.61,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26252,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 97.18,,OUTPCT LIMIT, 64.96,OTHER, 23.70, 119.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26253,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 52.80,,OUTPCT LIMIT, 34.98,OTHER, 11.54, 64.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26254,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 318.78,,OUTPCT LIMIT, 203.52,OTHER, 37.54, 390.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26255,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 91.20,,OUTPCT LIMIT, 61.71,OTHER, 25.39, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26256,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 39.80,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26257,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 39.80,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26258,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 39.80,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26259,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 44.18,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26260,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 44.18,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26261,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 44.18,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26262,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 20.96,,OUTPCT LIMIT, 14.14,OTHER, 5.66, 25.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26263,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 102.94,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26264,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 102.94,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26265,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 89.43,,OUTPCT LIMIT, 57.91,OTHER, 13.97, 109.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26266,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 57.46,,OUTPCT LIMIT, 37.55,OTHER, 10.37, 70.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26267,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 144.76,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26268,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 144.76,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26269,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 144.45,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26270,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 144.45,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26271,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 102.78,,OUTPCT LIMIT, 67.05,OTHER, 18.12, 125.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26272,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 110.40,,OUTPCT LIMIT, 74.92,OTHER, 31.62, 135.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26273,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 73.68,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26274,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 73.68,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26275,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 73.68,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26276,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 153.49,,OUTPCT LIMIT, 99.83,OTHER, 25.80, 188.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26277,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 240.80,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26278,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 212.30,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26279,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 212.30,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26280,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 212.30,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26281,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 212.30,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26282,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 212.30,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26283,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 237.29,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26284,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 143.25,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26285,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.87,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26286,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 34.40,,OUTPCT LIMIT, 25.93,OTHER, 18.49, 42.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26287,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 106.69,,OUTPCT LIMIT, 69.04,OTHER, 16.46, 130.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26288,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.26,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26289,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.26,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26290,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.26,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26291,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 83.52,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26292,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 83.52,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26293,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 83.52,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26294,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 83.52,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26295,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 108.24,,OUTPCT LIMIT, 70.04,OTHER, 16.66, 132.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26296,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 69.17,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26297,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 91.14,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26298,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 132.80,,OUTPCT LIMIT, 85.45,OTHER, 18.42, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26299,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 101.60,,OUTPCT LIMIT, 68.77,OTHER, 28.37, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26300,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 82.92,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26301,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 82.92,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26302,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 95.21,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26303,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 95.21,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26304,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 218.18,,OUTPCT LIMIT, 149.05,OTHER, 66.68, 267.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26305,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 52.00,,OUTPCT LIMIT, 43.46,OTHER, 27.95, 63.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26306,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 64.56,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26307,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 64.56,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26308,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 62.82,,OUTPCT LIMIT, 40.64,OTHER, 9.65, 76.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26309,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 320.73,,OUTPCT LIMIT, 204.04,OTHER, 34.72, 392.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26310,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 85.06,,OUTPCT LIMIT, 57.49,OTHER, 23.41, 104.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26311,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 251.90,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26312,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 251.90,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26313,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 133.34,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26314,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 97.22,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26315,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 175.20,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26316,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 175.20,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26317,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 169.86,,OUTPCT LIMIT, 110.95,OTHER, 30.54, 208.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26318,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 85.03,,OUTPCT LIMIT, 54.17,OTHER, 9.52, 104.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26319,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.99,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26320,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.99,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26321,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 133.02,,OUTPCT LIMIT, 86.15,OTHER, 20.81, 162.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26322,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 217.64,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26323,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 217.64,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26324,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 60.80,,OUTPCT LIMIT, 43.75,OTHER, 27.89, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26325,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 294.70,,OUTPCT LIMIT, 186.61,OTHER, 28.27, 361.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26326,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.80,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26327,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 75.68,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26328,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 54.99,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26329,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 54.99,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26330,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 44.62,,OUTPCT LIMIT, 28.87,OTHER, 6.85, 54.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26331,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 20.00,,OUTPCT LIMIT, 13.83,OTHER, 6.82, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26332,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 66.45,,OUTPCT LIMIT, 45.56,OTHER, 21.01, 81.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26333,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 140.19,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26334,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 140.19,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26335,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 153.12,,OUTPCT LIMIT, 102.79,OTHER, 39.19, 187.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26336,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 148.30,,OUTPCT LIMIT, 97.17,OTHER, 27.91, 181.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26337,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 132.25,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26338,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 142.67,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26339,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 142.67,,OUTPCT LIMIT, 93.39,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26340,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 38.34,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26341,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 38.34,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26342,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 92.70,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26343,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 92.70,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26344,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 92.70,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26345,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 65.44,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26346,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 65.44,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26347,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.34,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26348,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 318.47,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26349,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 141.49,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26350,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 122.02,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26351,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 321.90,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26352,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 208.38,,OUTPCT LIMIT, 136.35,OTHER, 38.44, 255.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26353,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 153.41,,OUTPCT LIMIT, 103.27,OTHER, 40.46, 187.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26354,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 113.60,,OUTPCT LIMIT, 76.88,OTHER, 31.67, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26355,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 281.60,,OUTPCT LIMIT, 178.83,OTHER, 29.15, 344.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26356,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 132.66,,OUTPCT LIMIT, 88.43,OTHER, 31.30, 162.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26357,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 46.48,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26358,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 46.48,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26359,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 72.30,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26360,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 72.30,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26361,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 14.84,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26362,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 284.14,,OUTPCT LIMIT, 180.72,OTHER, 30.61, 348.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26363,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 491.78,,OUTPCT LIMIT, 302.95,OTHER, 11.66, 602.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26364,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 119.86,,OUTPCT LIMIT, 81.90,OTHER, 36.67, 146.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26365,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 187.22,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26366,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 187.22,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26367,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 187.22,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26368,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 187.22,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26369,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 130.27,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26370,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 130.27,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26371,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 166.86,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26372,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 166.86,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26373,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 83.42,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26374,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 83.42,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26375,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 119.36,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26376,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 119.36,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26377,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 119.36,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26378,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 76.80,,OUTPCT LIMIT, 51.95,OTHER, 21.29, 94.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26379,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 111.03,,OUTPCT LIMIT, 73.53,OTHER, 24.19, 136.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26380,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 224.00,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26381,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 224.00,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26382,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 73.60,,OUTPCT LIMIT, 49.79,OTHER, 20.42, 90.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26383,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 59.86,,OUTPCT LIMIT, 38.32,OTHER, 7.46, 73.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26384,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 55.98,,OUTPCT LIMIT, 35.99,OTHER, 7.63, 68.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26385,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 88.69,,OUTPCT LIMIT, 58.51,OTHER, 18.37, 108.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26386,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 60.89,,OUTPCT LIMIT, 39.13,OTHER, 8.27, 74.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26387,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 122.13,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26388,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 122.13,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26389,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 119.74,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26390,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 119.74,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26391,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 199.02,,OUTPCT LIMIT, 126.89,OTHER, 22.69, 243.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26392,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 128.96,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26393,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 128.96,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26394,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 61.88,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26395,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 61.88,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26396,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 61.88,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26397,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 33.90,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26398,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 33.90,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26399,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 49.68,,OUTPCT LIMIT, 31.87,OTHER, 6.50, 60.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26400,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 61.20,,OUTPCT LIMIT, 39.10,OTHER, 7.32, 74.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26401,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 118.54,,OUTPCT LIMIT, 76.33,OTHER, 16.72, 145.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26402,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 162.20,,OUTPCT LIMIT, 103.71,OTHER, 19.75, 198.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26403,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 86.46,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26404,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 86.46,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26405,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 86.46,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26406,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 128.56,,OUTPCT LIMIT, 85.61,OTHER, 29.96, 157.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26407,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 150.52,,OUTPCT LIMIT, 97.04,OTHER, 21.67, 184.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26408,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 67.54,,OUTPCT LIMIT, 42.88,OTHER, 6.94, 82.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26409,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 69.62,,OUTPCT LIMIT, 43.80,OTHER, 5.47, 85.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26410,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 27.91,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26411,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 27.91,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26412,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 33.82,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26413,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 33.82,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26414,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26415,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.73,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26416,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 69.62,,OUTPCT LIMIT, 44.71,OTHER, 9.31, 85.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26417,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 59.45,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26418,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 59.45,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26419,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 31.20,,OUTPCT LIMIT, 19.92,OTHER, 3.66, 38.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26420,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 50.94,,OUTPCT LIMIT, 32.63,OTHER, 6.46, 62.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26421,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 148.49,,OUTPCT LIMIT, 96.77,OTHER, 25.78, 181.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26422,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 198.95,,OUTPCT LIMIT, 129.31,OTHER, 33.04, 243.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26423,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 207.20,,OUTPCT LIMIT, 130.54,OTHER, 17.06, 253.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26424,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 153.34,,OUTPCT LIMIT, 98.34,OTHER, 19.93, 187.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26425,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 137.20,,OUTPCT LIMIT, 89.00,OTHER, 22.06, 168.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26426,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 155.20,,OUTPCT LIMIT, 98.22,OTHER, 14.66, 190.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26427,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.05,,OUTPCT LIMIT, 54.63,OTHER, 13.99, 102.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26428,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 104.80,,OUTPCT LIMIT, 70.40,OTHER, 27.00, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26429,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 46.61,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26430,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 46.30,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26431,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 46.61,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26432,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 20.80,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26433,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 20.80,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26434,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 20.80,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26435,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 20.80,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26436,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 65.76,,OUTPCT LIMIT, 41.60,OTHER, 6.14, 80.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26437,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 41.60,,OUTPCT LIMIT, 26.32,OTHER, 3.89, 50.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26438,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 56.46,,OUTPCT LIMIT, 36.35,OTHER, 7.93, 69.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26439,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 136.00,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26440,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 59.90,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26441,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 121.22,,OUTPCT LIMIT, 76.67,OTHER, 11.26, 148.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26442,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 950.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26443,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 258.40,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26444,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26445,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26446,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26447,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26448,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26449,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26450,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26451,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26452,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26453,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26454,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26455,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26456,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26457,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26458,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26459,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26460,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26461,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26462,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26463,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26464,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26465,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26466,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26467,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26468,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26469,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26470,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26471,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26472,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26473,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26474,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26475,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26476,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26477,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26478,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26479,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26480,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 49.31,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26481,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26482,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26483,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26484,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26485,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 25.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26486,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26487,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26488,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26489,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26490,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26491,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26492,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26493,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26494,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26495,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26496,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26497,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26498,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26499,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26500,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26501,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26502,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26503,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.34,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26504,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 299.80,,OUTPCT LIMIT, 189.29,OTHER, 26.45, 367.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26505,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 183.05,,OUTPCT LIMIT, 115.17,OTHER, 14.46, 224.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26506,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 106.64,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26507,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 180.22,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26508,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 73.86,,OUTPCT LIMIT, 48.91,OTHER, 16.07, 90.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26509,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 70.00,,OUTPCT LIMIT, 45.23,OTHER, 10.51, 85.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26510,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 25.07,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26511,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 25.07,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26512,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 89.80,,OUTPCT LIMIT, 59.25,OTHER, 18.65, 110.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26513,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 139.67,,OUTPCT LIMIT, 93.98,OTHER, 36.65, 171.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26514,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 210.76,,OUTPCT LIMIT, 137.37,OTHER, 36.65, 258.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26515,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 119.52,,OUTPCT LIMIT, 78.46,OTHER, 23.14, 146.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26516,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 104.21,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26517,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 103.94,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26518,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 115.86,,OUTPCT LIMIT, 77.69,OTHER, 29.26, 141.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26519,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 96.24,,OUTPCT LIMIT, 63.19,OTHER, 18.65, 117.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26520,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 96.10,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26521,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 104.33,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26522,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 113.16,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26523,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 113.16,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26524,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 113.16,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26525,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 113.16,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26526,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 113.30,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26527,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 113.16,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26528,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 96.68,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26529,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 90.13,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26530,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 127.20,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26531,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 194.54,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26532,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 187.80,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26533,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 20.00,,OUTPCT LIMIT, 15.65,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26534,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 119.23,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26535,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 122.59,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26536,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 127.77,,OUTPCT LIMIT, 85.12,OTHER, 29.96, 156.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26537,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 157.79,,OUTPCT LIMIT, 103.45,OTHER, 29.96, 193.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26538,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 108.24,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26539,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 282.00,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26540,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 79.89,,OUTPCT LIMIT, 50.54,OTHER, 7.46, 97.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26541,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 133.05,,OUTPCT LIMIT, 88.87,OTHER, 32.17, 162.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26542,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 96.80,,OUTPCT LIMIT, 66.43,OTHER, 30.83, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26543,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 85.61,,OUTPCT LIMIT, 57.43,OTHER, 21.72, 104.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26544,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 421.00,,OUTPCT LIMIT, 265.06,OTHER, 33.95, 515.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26545,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 117.60,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26546,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 117.60,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26547,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 162.00,,OUTPCT LIMIT, 111.82,OTHER, 54.34, 198.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26548,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 262.32,,OUTPCT LIMIT, 176.22,OTHER, 67.64, 321.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26549,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 129.20,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26550,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 129.20,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26551,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 107.20,,OUTPCT LIMIT, 68.73,OTHER, 13.84, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26552,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 130.50,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26553,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 168.00,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26554,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 107.20,,OUTPCT LIMIT, 70.10,OTHER, 19.60, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26555,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 73.58,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26556,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 73.58,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26557,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 279.20,,OUTPCT LIMIT, 191.67,OTHER, 89.24, 342.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26558,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 14.96,,OUTPCT LIMIT, 12.31,OTHER, 8.04, 18.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26559,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 27.93,,OUTPCT LIMIT, 18.56,OTHER, 6.34, 34.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26560,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 50.86,,OUTPCT LIMIT, 36.21,OTHER, 21.67, 62.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26561,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.80,,OUTPCT LIMIT, 55.25,OTHER, 14.66, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26562,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 58.50,,OUTPCT LIMIT, 40.13,OTHER, 18.58, 71.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26563,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 101.60,,OUTPCT LIMIT, 66.54,OTHER, 19.00, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26564,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 135.22,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26565,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 135.22,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26566,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 135.22,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26567,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 37.07,,OUTPCT LIMIT, 26.75,OTHER, 17.29, 45.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26568,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 77.54,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26569,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 208.00,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26570,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 75.20,,OUTPCT LIMIT, 50.83,OTHER, 20.72, 92.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26571,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 87.20,,OUTPCT LIMIT, 59.00,OTHER, 24.26, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26572,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 97.01,,OUTPCT LIMIT, 64.46,OTHER, 22.02, 118.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26573,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 87.29,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26574,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 87.29,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26575,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 146.38,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26576,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 88.10,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26577,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 88.10,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26578,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 98.40,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26579,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 98.40,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26580,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 63.20,,OUTPCT LIMIT, 43.51,OTHER, 20.72, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26581,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 70.70,,OUTPCT LIMIT, 47.68,OTHER, 19.00, 86.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26582,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.80,,OUTPCT LIMIT, 58.39,OTHER, 27.86, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26583,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 119.17,,OUTPCT LIMIT, 77.47,OTHER, 19.86, 145.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26584,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 94.70,,OUTPCT LIMIT, 62.50,OTHER, 19.74, 116.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26585,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 69.82,,OUTPCT LIMIT, 46.75,OTHER, 17.35, 85.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26586,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 60.80,,OUTPCT LIMIT, 41.14,OTHER, 16.94, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26587,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 103.86,,OUTPCT LIMIT, 67.08,OTHER, 15.47, 127.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26588,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 75.82,,OUTPCT LIMIT, 50.52,OTHER, 17.84, 92.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26589,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 39.84,,OUTPCT LIMIT, 28.18,OTHER, 16.21, 48.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26590,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 78.75,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26591,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 78.75,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26592,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 60.00,,OUTPCT LIMIT, 41.16,OTHER, 19.07, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26593,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 67.46,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26594,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 67.46,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26595,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 67.46,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26596,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 69.80,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26597,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 72.20,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26598,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 72.20,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26599,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 73.46,,OUTPCT LIMIT, 49.38,OTHER, 19.07, 89.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26600,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 124.01,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26601,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 124.01,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26602,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 585.43,,OUTPCT LIMIT, 361.76,OTHER, 18.55, 717.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26603,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 256.80,,OUTPCT LIMIT, 161.64,OTHER, 20.54, 314.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26604,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 223.82,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26605,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 223.82,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26606,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 122.32,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26607,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 122.32,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26608,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 122.32,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26609,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 191.20,,OUTPCT LIMIT, 152.44,OTHER, 102.77, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26610,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 344.69,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26611,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 344.69,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26612,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 344.69,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26613,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 130.93,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26614,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 130.93,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26615,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 130.93,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26616,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 130.93,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26617,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 130.93,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26618,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 237.69,,OUTPCT LIMIT, 146.86,OTHER, 7.46, 291.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26619,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 88.00,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26620,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 88.00,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26621,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 88.00,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26622,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 72.86,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26623,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 69.25,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26624,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 72.86,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26625,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 344.69,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26626,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 344.69,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26627,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 313.20,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26628,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 111.60,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26629,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 111.60,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26630,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 475.38,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26631,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 475.38,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26632,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 475.38,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26633,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 475.38,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26634,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 475.38,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26635,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 475.38,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26636,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 111.60,,OUTPCT LIMIT, 76.50,OTHER, 35.20, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26637,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 208.80,,OUTPCT LIMIT, 149.18,OTHER, 91.25, 255.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26638,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 127.57,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26639,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 127.57,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26640,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 45.10,,OUTPCT LIMIT, 30.76,OTHER, 13.60, 55.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26641,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 114.16,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26642,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 114.16,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26643,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 122.90,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26644,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 122.90,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26645,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 124.87,,OUTPCT LIMIT, 78.99,OTHER, 11.64, 152.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26646,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 72.09,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26647,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 72.09,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26648,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 72.09,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26649,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 63.38,,OUTPCT LIMIT, 40.96,OTHER, 9.55, 77.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26650,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.66,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26651,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.66,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26652,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.66,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26653,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 130.22,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26654,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 130.22,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26655,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 117.73,,OUTPCT LIMIT, 74.74,OTHER, 12.11, 144.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26656,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 143.02,,OUTPCT LIMIT, 91.00,OTHER, 15.55, 175.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26657,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 106.91,,OUTPCT LIMIT, 68.31,OTHER, 12.82, 130.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26658,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 26.40,,OUTPCT LIMIT, 17.74,OTHER, 6.84, 32.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26659,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 33.46,,OUTPCT LIMIT, 22.99,OTHER, 10.78, 40.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26660,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 46.40,,OUTPCT LIMIT, 29.95,OTHER, 6.84, 56.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26661,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 64.62,,OUTPCT LIMIT, 42.41,OTHER, 12.46, 79.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26662,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 45.27,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26663,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 42.15,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26664,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 42.15,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26665,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 42.31,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26666,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 42.31,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26667,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 59.46,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26668,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 59.46,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26669,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 43.08,,OUTPCT LIMIT, 28.29,OTHER, 8.38, 52.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26670,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 101.60,,OUTPCT LIMIT, 68.72,OTHER, 28.16, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26671,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 483.76,,OUTPCT LIMIT, 299.39,OTHER, 17.26, 592.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26672,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 60.82,,OUTPCT LIMIT, 40.67,OTHER, 14.88, 74.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26673,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 64.10,,OUTPCT LIMIT, 43.08,OTHER, 16.61, 78.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26674,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 191.20,,OUTPCT LIMIT, 121.25,OTHER, 19.08, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26675,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 101.60,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26676,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 154.40,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26677,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 154.41,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26678,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 154.40,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26679,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 154.40,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26680,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 154.40,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26681,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 301.72,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26682,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 301.72,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26683,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 125.70,,OUTPCT LIMIT, 100.71,OTHER, 67.57, 153.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26684,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 338.78,,OUTPCT LIMIT, 221.47,OTHER, 61.69, 415.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26685,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 105.51,,OUTPCT LIMIT, 76.43,OTHER, 50.53, 129.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26686,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 386.40,,OUTPCT LIMIT, 265.03,OTHER, 122.54, 473.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26687,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 154.41,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26688,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 120.00,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26689,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 120.00,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26690,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 496.05,,OUTPCT LIMIT, 445.68,OTHER, 266.63, 607.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26691,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 80.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26692,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 80.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26693,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 80.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26694,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 298.10,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26695,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 298.10,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26696,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26697,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 264.80,,OUTPCT LIMIT, 173.66,OTHER, 50.53, 324.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26698,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 101.60,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26699,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 140.16,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26700,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 489.55,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26701,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 215.98,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26702,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 215.98,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26703,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 92.70,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26704,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 92.70,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26705,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 63.20,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26706,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 63.20,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26707,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 63.20,,OUTPCT LIMIT, 44.25,OTHER, 23.81, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26708,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 20.00,,OUTPCT LIMIT, 17.88,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26709,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 155.03,,OUTPCT LIMIT, 100.14,OTHER, 23.14, 189.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26710,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1167.20,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26711,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1167.20,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26712,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 83.20,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26713,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 83.20,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26714,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 444.00,,OUTPCT LIMIT, 294.34,OTHER, 97.97, 543.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26715,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26716,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26717,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 24.80,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26718,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 24.80,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26719,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 89.93,,OUTPCT LIMIT, 56.81,OTHER, 8.06, 110.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26720,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 61.38,,OUTPCT LIMIT, 39.98,OTHER, 10.56, 75.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26721,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 61.60,,OUTPCT LIMIT, 41.73,OTHER, 17.35, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26722,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 4745.94,,OUTPCT LIMIT, 3802.17,OTHER, 2550.94, 5813.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26723,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 90.13,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26724,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 90.13,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26725,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 23.60,,OUTPCT LIMIT, 23.30,OTHER, 12.69, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26726,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 47.60,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26727,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 23.80,,OUTPCT LIMIT, 23.42,OTHER, 12.79, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26728,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 103.20,,OUTPCT LIMIT, 82.68,OTHER, 55.47, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26729,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26730,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 122.40,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26731,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 122.40,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26732,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 111.16,,OUTPCT LIMIT, 89.06,OTHER, 59.75, 136.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26733,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 40.00,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26734,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 40.00,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26735,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 474.71,,OUTPCT LIMIT, 356.50,OTHER, 255.16, 581.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26736,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 991.83,,OUTPCT LIMIT, 687.64,OTHER, 345.38, 1214.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26737,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 251.60,,OUTPCT LIMIT, 201.57,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26738,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26739,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26740,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.00,,OUTPCT LIMIT, 60.00,OTHER, 36.55, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26741,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 41.16,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26742,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 41.16,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26743,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26744,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26745,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26746,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 8.80,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26747,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 8.80,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26748,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 8.80,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26749,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 8.80,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26750,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 63.79,,OUTPCT LIMIT, 51.11,OTHER, 34.29, 78.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26751,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 109.37,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26752,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 109.37,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26753,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26754,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 126.24,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26755,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 126.24,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26756,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26757,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26758,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 136.73,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26759,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 136.73,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26760,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 8.00,,OUTPCT LIMIT, 12.78,OTHER, 4.30, 33.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26761,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 26.45,,OUTPCT LIMIT, 17.36,OTHER, 5.09, 32.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26762,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 243.13,,OUTPCT LIMIT, 184.48,OTHER, 130.68, 297.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26763,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 272.41,,OUTPCT LIMIT, 202.35,OTHER, 146.42, 333.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26764,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 118.35,,OUTPCT LIMIT, 99.37,OTHER, 63.61, 144.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26765,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 121.66,,OUTPCT LIMIT, 88.44,OTHER, 59.56, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26766,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 156.70,,OUTPCT LIMIT, 131.72,OTHER, 84.22, 191.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26767,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 154.06,,OUTPCT LIMIT, 117.05,OTHER, 82.81, 188.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26768,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 235.38,,OUTPCT LIMIT, 179.75,OTHER, 126.51, 288.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26769,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 203.64,,OUTPCT LIMIT, 158.52,OTHER, 109.46, 249.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26770,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 245.96,,OUTPCT LIMIT, 186.21,OTHER, 132.20, 301.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26771,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 117.69,,OUTPCT LIMIT, 83.96,OTHER, 50.93, 144.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26772,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 189.76,,OUTPCT LIMIT, 167.44,OTHER, 102.00, 232.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26773,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 197.69,,OUTPCT LIMIT, 172.28,OTHER, 106.26, 242.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26774,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 47.61,,OUTPCT LIMIT, 49.86,OTHER, 25.59, 87.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26775,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 198.35,,OUTPCT LIMIT, 141.43,OTHER, 85.51, 242.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26776,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.50,,OUTPCT LIMIT, 69.71,OTHER, 45.42, 103.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26777,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 224.14,,OUTPCT LIMIT, 177.65,OTHER, 120.47, 274.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26778,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 243.47,,OUTPCT LIMIT, 189.46,OTHER, 130.87, 298.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26779,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 391.70,,OUTPCT LIMIT, 279.93,OTHER, 171.54, 479.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26780,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 367.23,,OUTPCT LIMIT, 265.00,OTHER, 171.54, 449.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26781,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 201.27,,OUTPCT LIMIT, 149.90,OTHER, 108.18, 246.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26782,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 255.64,,OUTPCT LIMIT, 167.02,OTHER, 46.09, 313.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26783,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 106.70,,OUTPCT LIMIT, 76.10,OTHER, 46.09, 130.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26784,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 223.42,,OUTPCT LIMIT, 147.35,OTHER, 46.09, 273.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26785,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 323.76,,OUTPCT LIMIT, 227.22,OTHER, 124.32, 396.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26786,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 435.60,,OUTPCT LIMIT, 295.49,OTHER, 124.32, 533.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26787,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 138.92,,OUTPCT LIMIT, 114.40,OTHER, 74.67, 170.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26788,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 206.23,,OUTPCT LIMIT, 155.48,OTHER, 110.85, 252.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26789,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 31.96,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26790,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 31.96,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26791,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 31.96,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26792,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 15.64,,OUTPCT LIMIT, 36.72,OTHER, 8.41, 114.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26793,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 294.68,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26794,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 294.68,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26795,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 727.70,,OUTPCT LIMIT, 526.62,OTHER, 346.21, 891.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26796,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 290.83,OTHER, 143.52, 346.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26797,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 266.62,,OUTPCT LIMIT, 266.67,OTHER, 147.17, 326.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26798,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 246.40,,OUTPCT LIMIT, 162.12,OTHER, 49.24, 301.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26799,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 198.40,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26800,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 198.40,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26801,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 253.60,,OUTPCT LIMIT, 166.97,OTHER, 51.13, 310.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26802,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 70.09,,OUTPCT LIMIT, 54.96,OTHER, 37.67, 85.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26803,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 121.66,,OUTPCT LIMIT, 86.43,OTHER, 51.13, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26804,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1301.34,,OUTPCT LIMIT, 950.56,OTHER, 656.16, 1594.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26805,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 375.80,OTHER, 121.44, 656.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26806,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 744.00,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26807,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 744.00,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26808,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26809,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26810,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 881.82,,OUTPCT LIMIT, 591.97,OTHER, 225.62, 1080.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26811,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26812,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 372.55,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26813,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 372.55,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26814,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 197.77,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26815,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 835.42,,OUTPCT LIMIT, 563.65,OTHER, 225.62, 1023.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26816,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26817,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 130.40,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26818,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 130.40,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26819,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26820,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26821,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 400.00,,OUTPCT LIMIT, 297.88,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26822,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26823,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 374.20,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26824,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 374.20,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26825,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26826,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26827,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1015.57,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26828,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1015.57,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26829,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 539.58,,OUTPCT LIMIT, 383.08,OTHER, 225.62, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26830,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1015.57,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26831,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26832,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26833,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26834,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26835,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 539.58,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26836,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 539.58,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26837,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 539.58,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26838,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 539.58,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26839,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26840,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26841,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26842,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26843,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 985.70,,OUTPCT LIMIT, 655.39,OTHER, 225.62, 1207.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26844,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26845,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2072.80,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26846,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1119.58,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26847,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 348.80,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26848,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 73.60,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26849,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 842.70,,OUTPCT LIMIT, 547.41,OTHER, 138.71, 1032.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26850,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 193.27,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26851,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 193.27,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26852,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 234.02,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26853,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 234.02,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26854,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 489.90,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26855,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 642.40,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26856,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 705.60,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26857,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 489.90,,OUTPCT LIMIT, 332.46,OTHER, 140.42, 600.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26858,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 298.21,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26859,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 298.21,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26860,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 193.27,,OUTPCT LIMIT, 174.98,OTHER, 103.88, 239.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26861,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 193.27,,OUTPCT LIMIT, 136.10,OTHER, 76.16, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26862,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 138.40,,OUTPCT LIMIT, 140.33,OTHER, 74.39, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26863,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 340.00,,OUTPCT LIMIT, 228.33,OTHER, 87.35, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26864,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 42.67,,OUTPCT LIMIT, 34.19,OTHER, 22.94, 52.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26865,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 83.20,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26866,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 262.12,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26867,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 262.12,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26868,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 114.74,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26869,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 114.74,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26870,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 588.95,,OUTPCT LIMIT, 415.63,OTHER, 235.80, 721.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26871,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2600.00,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26872,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2600.00,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26873,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3120.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26874,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3120.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26875,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3120.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26876,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 216.98,,OUTPCT LIMIT, 152.82,OTHER, 85.61, 265.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26877,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 237.02,,OUTPCT LIMIT, 165.98,OTHER, 89.47, 290.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26878,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 384.22,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26879,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 384.22,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26880,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 144.16,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26881,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 144.16,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26882,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 457.33,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26883,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 457.33,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26884,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 457.33,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26885,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 131.76,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26886,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 131.82,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26887,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 157.14,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26888,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 157.14,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26889,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 115.15,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26890,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 115.15,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26891,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 123.11,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26892,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 123.11,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26893,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 47.60,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26894,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 47.60,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26895,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 240.67,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26896,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 240.67,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26897,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 136.74,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26898,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 136.74,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26899,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 138.00,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26900,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 138.00,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26901,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 70.37,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26902,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 70.37,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26903,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 77.23,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26904,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 77.23,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26905,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.63,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26906,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.63,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26907,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.63,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26908,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 336.00,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26909,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 107.88,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26910,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 107.88,,OUTPCT LIMIT, 72.71,OTHER, 28.82, 132.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26911,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 98.30,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26912,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 98.24,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26913,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 98.30,,OUTPCT LIMIT, 74.35,OTHER, 52.84, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26914,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 104.85,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26915,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 104.85,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26916,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 104.85,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26917,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 76.10,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26918,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 76.10,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26919,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 54.10,,OUTPCT LIMIT, 47.68,OTHER, 29.08, 66.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26920,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 143.20,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26921,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 143.20,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26922,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 143.20,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26923,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 172.00,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26924,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 172.00,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26925,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 172.00,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26926,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 98.14,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26927,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 98.14,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26928,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 98.14,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26929,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 35.20,,OUTPCT LIMIT, 30.33,OTHER, 18.92, 43.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26930,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 212.03,,OUTPCT LIMIT, 178.52,OTHER, 113.97, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26931,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 251.60,,OUTPCT LIMIT, 202.67,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26932,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 238.22,,OUTPCT LIMIT, 194.50,OTHER, 128.04, 291.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26933,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 118.69,,OUTPCT LIMIT, 106.37,OTHER, 63.79, 145.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26934,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 203.46,,OUTPCT LIMIT, 173.75,OTHER, 109.36, 249.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26935,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 215.07,,OUTPCT LIMIT, 180.83,OTHER, 115.60, 263.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26936,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 253.83,,OUTPCT LIMIT, 204.49,OTHER, 136.43, 310.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26937,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 122.59,,OUTPCT LIMIT, 108.91,OTHER, 65.89, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26938,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 96.57,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26939,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 96.57,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26940,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 96.57,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26941,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 58.72,,OUTPCT LIMIT, 44.69,OTHER, 31.56, 71.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26942,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 102.12,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26943,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 102.12,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26944,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 70.90,,OUTPCT LIMIT, 59.17,OTHER, 38.11, 86.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26945,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 92.80,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26946,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 92.80,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26947,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 92.80,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26948,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 23.20,,OUTPCT LIMIT, 68.90,OTHER, 12.81, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26949,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 115.01,,OUTPCT LIMIT, 93.12,OTHER, 61.82, 140.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26950,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 96.80,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26951,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 212.03,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26952,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 99.20,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26953,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 99.20,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26954,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 99.20,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26955,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 60.00,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26956,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 83.20,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26957,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 112.80,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26958,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 83.20,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26959,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 112.80,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26960,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 60.00,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26961,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 60.00,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26962,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 240.00,,OUTPCT LIMIT, 192.27,OTHER, 129.00, 294.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26963,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26964,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26965,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 193.27,,OUTPCT LIMIT, 145.27,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26966,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 119.00,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26967,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 119.00,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26968,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 201.66,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26969,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 201.66,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26970,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 315.52,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26971,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 315.52,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26972,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 393.04,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26973,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 393.04,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26974,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 38.08,,OUTPCT LIMIT, 30.51,OTHER, 20.47, 46.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26975,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 82.96,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26976,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 82.96,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26977,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 138.72,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26978,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 138.72,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26979,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 204.68,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26980,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 204.68,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26981,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 274.04,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26982,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 274.04,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26983,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 272.00,,OUTPCT LIMIT, 272.06,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26984,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 336.80,,OUTPCT LIMIT, 336.87,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26985,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 116.00,,OUTPCT LIMIT, 111.61,OTHER, 64.03, 142.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26986,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 141.60,,OUTPCT LIMIT, 149.82,OTHER, 78.16, 173.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26987,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 204.80,,OUTPCT LIMIT, 220.11,OTHER, 113.05, 250.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26988,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 215.14,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26989,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 215.14,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26990,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 200.80,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26991,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 200.80,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26992,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 332.80,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26993,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 332.80,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26994,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 236.80,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26995,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 236.80,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26996,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 525.87,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26997,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 525.87,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26998,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 272.00,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 26999,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 272.00,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27000,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 824.86,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27001,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 824.86,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27002,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 336.80,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27003,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 336.80,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27004,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1375.82,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27005,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1375.82,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27006,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 400.80,,OUTPCT LIMIT, 429.06,OTHER, 221.24, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27007,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2200.62,,OUTPCT LIMIT, 1514.86,OTHER, 720.78, 2695.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27008,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 806.73,,OUTPCT LIMIT, 646.30,OTHER, 433.62, 988.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27009,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 24.00,,OUTPCT LIMIT, 19.23,OTHER, 12.90, 29.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27010,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 133.96,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27011,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 133.96,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27012,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 210.80,,OUTPCT LIMIT, 167.97,OTHER, 113.31, 258.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27013,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 219.64,,OUTPCT LIMIT, 173.37,OTHER, 118.06, 269.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27014,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 229.16,,OUTPCT LIMIT, 179.18,OTHER, 123.17, 280.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27015,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 259.08,,OUTPCT LIMIT, 197.44,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27016,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 251.60,,OUTPCT LIMIT, 192.88,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27017,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 290.36,,OUTPCT LIMIT, 232.62,OTHER, 156.07, 355.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27018,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 315.52,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27019,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 189.72,,OUTPCT LIMIT, 155.10,OTHER, 101.97, 232.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27020,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 202.64,,OUTPCT LIMIT, 162.99,OTHER, 108.92, 248.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27021,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 221.00,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27022,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 221.00,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27023,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 221.00,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27024,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 225.76,,OUTPCT LIMIT, 177.10,OTHER, 121.35, 276.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27025,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 240.72,,OUTPCT LIMIT, 192.85,OTHER, 129.39, 294.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27026,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 259.08,,OUTPCT LIMIT, 207.56,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27027,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 69.36,,OUTPCT LIMIT, 55.57,OTHER, 37.28, 84.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27028,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 119.00,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27029,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 56.00,,OUTPCT LIMIT, 44.86,OTHER, 30.10, 68.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27030,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 212.84,,OUTPCT LIMIT, 170.52,OTHER, 114.40, 260.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27031,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 42.30,,OUTPCT LIMIT, 33.14,OTHER, 22.74, 51.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27032,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 52.36,,OUTPCT LIMIT, 39.28,OTHER, 28.14, 64.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27033,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 75.50,,OUTPCT LIMIT, 60.49,OTHER, 40.58, 92.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27034,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 17.60,,OUTPCT LIMIT, 14.10,OTHER, 9.46, 21.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27035,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 17.60,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27036,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 119.00,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27037,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 204.00,,OUTPCT LIMIT, 148.65,OTHER, 101.33, 249.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27038,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 220.00,,OUTPCT LIMIT, 166.04,OTHER, 118.25, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27039,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 10.20,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27040,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 10.20,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27041,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 308.00,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27042,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 308.00,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27043,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 485.60,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27044,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 485.60,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27045,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 284.00,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27046,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 284.00,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27047,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 409.60,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27048,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 409.60,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27049,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 702.40,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27050,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 702.40,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27051,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 780.00,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27052,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 780.00,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27053,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 108.80,,OUTPCT LIMIT, 87.16,OTHER, 58.48, 133.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27054,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 51.20,,OUTPCT LIMIT, 41.02,OTHER, 27.52, 62.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27055,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 60.00,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27056,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2396.80,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27057,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2396.80,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27058,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2608.80,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27059,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2608.80,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27060,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1840.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27061,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1840.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27062,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1840.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27063,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1600.00,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27064,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1600.00,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27065,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1600.00,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27066,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1600.00,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27067,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 15.31,,OUTPCT LIMIT, 9.74,OTHER, 1.66, 18.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27068,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 90.13,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27069,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 4.80,,OUTPCT LIMIT, 11.82,OTHER, 2.58, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27070,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 72.08,,OUTPCT LIMIT, 57.75,OTHER, 38.74, 88.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27071,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 37.40,,OUTPCT LIMIT, 29.96,OTHER, 20.10, 45.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27072,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 132.25,,OUTPCT LIMIT, 88.75,OTHER, 33.71, 162.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27073,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 83.20,,OUTPCT LIMIT, 58.81,OTHER, 33.71, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27074,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 312.80,,OUTPCT LIMIT, 250.60,OTHER, 168.13, 383.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27075,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 315.52,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27076,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 315.52,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27077,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 34.00,,OUTPCT LIMIT, 35.44,OTHER, 18.28, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27078,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 48.96,,OUTPCT LIMIT, 44.57,OTHER, 26.32, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27079,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 54.40,,OUTPCT LIMIT, 43.58,OTHER, 29.24, 66.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27080,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27081,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 207.84,,OUTPCT LIMIT, 166.51,OTHER, 111.71, 254.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27082,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 75.02,,OUTPCT LIMIT, 60.10,OTHER, 40.32, 91.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27083,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 6.14,,OUTPCT LIMIT, 4.92,OTHER, 3.30, 7.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27084,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 5.95,,OUTPCT LIMIT, 4.77,OTHER, 3.20, 7.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27085,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 16.26,,OUTPCT LIMIT, 13.02,OTHER, 8.74, 19.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27086,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 168.00,,OUTPCT LIMIT, 134.59,OTHER, 90.30, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27087,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1.70,,OUTPCT LIMIT, 1.36,OTHER, .91, 2.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27088,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2.62,,OUTPCT LIMIT, 2.10,OTHER, 1.41, 3.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27089,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 32.34,,OUTPCT LIMIT, 25.91,OTHER, 17.38, 39.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27090,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 116.09,,OUTPCT LIMIT, 93.00,OTHER, 62.40, 142.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27091,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1.82,,OUTPCT LIMIT, 1.46,OTHER, .98, 2.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27092,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1.28,,OUTPCT LIMIT, 1.03,OTHER, .69, 1.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27093,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 6.43,,OUTPCT LIMIT, 5.15,OTHER, 3.46, 7.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27094,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 14.30,,OUTPCT LIMIT, 11.46,OTHER, 7.69, 17.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27095,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 5.47,,OUTPCT LIMIT, 4.38,OTHER, 2.94, 6.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27096,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3.20,,OUTPCT LIMIT, 2.56,OTHER, 1.72, 3.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27097,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 9.34,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27098,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 10.40,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27099,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 54.66,,OUTPCT LIMIT, 43.79,OTHER, 29.38, 66.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27100,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 28.74,,OUTPCT LIMIT, 23.02,OTHER, 15.45, 35.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27101,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 8.42,,OUTPCT LIMIT, 6.74,OTHER, 4.52, 10.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27102,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 6.50,,OUTPCT LIMIT, 5.20,OTHER, 3.49, 7.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27103,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 319.20,,OUTPCT LIMIT, 575.18,OTHER, 171.57, 1597.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27104,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 319.20,,OUTPCT LIMIT, 690.66,OTHER, 171.57, 2082.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27105,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 319.20,,OUTPCT LIMIT, 656.15,OTHER, 171.57, 1937.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27106,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 319.20,,OUTPCT LIMIT, 607.70,OTHER, 171.57, 1734.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27107,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 399.20,,OUTPCT LIMIT, 735.35,OTHER, 214.57, 2065.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27108,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 684.00,,OUTPCT LIMIT, 421.89,OTHER, 18.42, 837.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27109,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3.84,,OUTPCT LIMIT, 3.08,OTHER, 2.06, 4.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27110,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 278.40,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27111,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 278.40,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27112,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 278.40,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27113,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 278.40,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27114,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 278.40,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27115,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 278.40,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27116,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 278.40,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27117,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 278.40,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27118,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 278.40,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27119,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 278.40,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27120,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 278.40,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27121,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 278.40,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27122,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 332.00,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27123,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 332.00,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27124,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 332.00,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27125,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 332.00,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27126,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27127,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27128,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27129,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27130,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27131,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27132,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27133,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27134,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27135,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27136,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27137,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27138,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27139,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27140,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27141,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27142,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27143,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27144,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27145,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1060.80,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27146,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 85.00,,OUTPCT LIMIT, 62.01,OTHER, 42.53, 104.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27147,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 91.20,,OUTPCT LIMIT, 73.06,OTHER, 49.02, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27148,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 80.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27149,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 400.00,,OUTPCT LIMIT, 320.46,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27150,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 33.60,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27151,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2.40,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27152,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 28.00,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27153,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2.40,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27154,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 21.60,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27155,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2.40,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27156,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 12.00,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27157,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2.52,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27158,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 60.00,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27159,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2.52,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27160,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3.62,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27161,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 80.80,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27162,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 4.80,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27163,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 4.80,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27164,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 147.14,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27165,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 4.80,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27166,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 144.00,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27167,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 46.40,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27168,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 46.40,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27169,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 265.73,,OUTPCT LIMIT, 212.89,OTHER, 142.83, 325.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27170,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 97.43,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27171,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 60.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27172,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 787.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27173,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 573.63,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27174,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 7.20,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27175,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 4.80,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27176,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 80.80,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27177,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 80.80,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27178,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 80.80,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27179,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 80.80,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27180,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 80.80,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27181,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 80.80,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27182,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 80.80,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27183,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 4.80,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27184,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 80.80,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27185,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 81.60,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27186,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 57.47,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27187,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 57.47,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27188,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 60.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27189,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 110.06,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27190,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2.40,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27191,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 12.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27192,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 12.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27193,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 12.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27194,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 14.40,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27195,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 19.20,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27196,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2.40,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27197,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 22.82,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27198,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 22.82,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27199,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 24.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27200,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 24.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27201,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 24.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27202,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 24.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27203,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2.40,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27204,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2.39,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27205,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 37.19,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27206,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 8.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27207,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 2.52,,OUTPCT LIMIT, 2.02,OTHER, 1.35, 3.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27208,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 400.80,,OUTPCT LIMIT, 321.10,OTHER, 215.43, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27209,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 457.60,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27210,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27211,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27212,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27213,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27214,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27215,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27216,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27217,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 27.22,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27218,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 121.75,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27219,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 114.11,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27220,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 74.55,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27221,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 68.43,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27222,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 208.23,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27223,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 6084.56,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27224,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 36.18,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27225,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1424.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27226,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1424.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27227,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1424.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27228,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1424.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27229,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1424.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27230,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1424.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27231,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1920.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27232,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1424.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27233,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1424.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27234,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1424.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27235,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1424.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27236,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1424.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27237,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1424.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27238,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1120.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27239,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1120.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27240,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 1120.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27241,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27242,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27243,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27244,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 84.00,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27245,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27246,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 53.70,,OUTPCT LIMIT, 43.03,OTHER, 28.87, 65.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27247,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 8.00,,OUTPCT LIMIT, 6.41,OTHER, 4.30, 9.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27248,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 4640.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27249,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3840.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27250,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3840.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27251,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 3840.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27252,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27253,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27254,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 348.80,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27255,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 235.38,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27256,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 242.65,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27257,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 197.69,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27258,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 219.64,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27259,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 453.60,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27260,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 138.72,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27261,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 80.80,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27262,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 81.33,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27263,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 119.00,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27264,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 13.60,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27265,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 22.40,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27266,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27267,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27268,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27269,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27270,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27271,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27272,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27273,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27274,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27275,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27276,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27277,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27278,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, 260.00,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27279,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBYTERIAN,PRESBYTERIAN COMMERCIAL, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 27280,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27281,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27282,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27283,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27284,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27285,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27286,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27287,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27288,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27289,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27290,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27291,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27292,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27293,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27294,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27295,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27296,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27297,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27298,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 209.32,,OUTPAT REV HCPCS COMBO 1, 271.70,OTHER, 142.76, 477.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27299,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 209.32,,OUTPAT REV HCPCS COMBO 1, 271.70,OTHER, 142.76, 477.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27300,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 118.79,,OUTPAT REV HCPCS COMBO 1, 168.89,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27301,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27302,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 211.23,,OUTPAT REV HCPCS COMBO 1, 273.87,OTHER, 142.76, 481.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27303,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27304,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 155.70,,OUTPAT REV HCPCS COMBO 1, 242.16,OTHER, 155.70, 354.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27305,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27306,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27307,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27308,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27309,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27310,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27311,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27312,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27313,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27314,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27315,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27316,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27317,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27318,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27319,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27320,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27321,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27322,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27323,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27324,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27325,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27326,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27327,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27328,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27329,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27330,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27331,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27332,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27333,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27334,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27335,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27336,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27337,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27338,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27339,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27340,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27341,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27342,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27343,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27344,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27345,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27346,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27347,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27348,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 145.30,,OUTPAT REV HCPCS COMBO 1, 185.53,OTHER, 86.20, 331.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27349,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27350,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27351,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27352,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27353,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27354,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27355,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 165.01,,OUTPAT REV HCPCS COMBO 1, 278.63,OTHER, 165.01, 383.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27356,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 296.20,,OUTPAT REV HCPCS COMBO 1, 427.61,OTHER, 296.20, 675.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27357,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 179.25,,OUTPAT REV HCPCS COMBO 1, 237.66,OTHER, 143.26, 408.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27358,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 193.33,,OUTPAT REV HCPCS COMBO 1, 253.66,OTHER, 143.26, 440.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27359,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 209.63,,OUTPAT REV HCPCS COMBO 1, 272.17,OTHER, 143.26, 477.75,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27360,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 191.34,,OUTPAT REV HCPCS COMBO 1, 251.39,OTHER, 143.26, 436.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27361,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27362,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 202.93,,OUTPAT REV HCPCS COMBO 1, 264.56,OTHER, 143.26, 462.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27363,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 204.98,,OUTPAT REV HCPCS COMBO 1, 306.35,OTHER, 204.98, 467.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27364,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27365,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27366,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 230.23,,OUTPAT REV HCPCS COMBO 1, 293.08,OTHER, 132.82, 524.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27367,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 836.72,,OUTPAT REV HCPCS COMBO 1, 1023.77,OTHER, 309.01, 1906.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27368,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27369,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1408.79,,OUTPAT REV HCPCS COMBO 1, 1703.49,OTHER, 435.32, 3210.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27370,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27371,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27372,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27373,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27374,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 145.30,,OUTPAT REV HCPCS COMBO 1, 200.99,OTHER, 145.30, 331.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27375,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27376,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27377,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27378,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27379,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27380,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27381,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27382,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 57.02,,OUTPAT REV HCPCS COMBO 1, 124.43,OTHER, 57.02, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27383,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 53.32,,OUTPAT REV HCPCS COMBO 1, 120.23,OTHER, 53.32, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27384,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 62.14,,OUTPAT REV HCPCS COMBO 1, 130.25,OTHER, 62.14, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27385,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 62.14,,OUTPAT REV HCPCS COMBO 1, 130.25,OTHER, 62.14, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27386,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27387,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27388,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 339.79,,OUTPAT REV HCPCS COMBO 1, 424.57,OTHER, 162.56, 774.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27389,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 260.82,,OUTPAT REV HCPCS COMBO 1, 334.89,OTHER, 162.56, 594.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27390,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 496.58,,OUTPAT REV HCPCS COMBO 1, 675.88,OTHER, 470.23, 1131.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27391,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 406.01,,OUTPAT REV HCPCS COMBO 1, 499.77,OTHER, 162.56, 925.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27392,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 406.01,,OUTPAT REV HCPCS COMBO 1, 499.77,OTHER, 162.56, 925.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27393,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 148.80,,OUTPAT REV HCPCS COMBO 1, 207.69,OTHER, 148.80, 339.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27394,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 148.80,,OUTPAT REV HCPCS COMBO 1, 207.69,OTHER, 148.80, 339.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27395,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 133.93,,OUTPAT REV HCPCS COMBO 1, 176.70,OTHER, 103.34, 305.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27396,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 485.88,,OUTPAT REV HCPCS COMBO 1, 596.69,OTHER, 188.66, 1107.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27397,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 485.88,,OUTPAT REV HCPCS COMBO 1, 596.69,OTHER, 188.66, 1107.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27398,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 845.35,,OUTPAT REV HCPCS COMBO 1, 1089.64,OTHER, 544.52, 1926.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27399,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 15.05,,OUTPAT REV HCPCS COMBO 1, 22.43,OTHER, 15.05, 34.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27400,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27401,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27402,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27403,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27404,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27405,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27406,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 16.02,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27407,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 440.37,,OUTPAT REV HCPCS COMBO 1, 579.04,OTHER, 331.58, 1003.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27408,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27409,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27410,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27411,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27412,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27413,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 124.21,OTHER, 26.22, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27414,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 124.21,OTHER, 26.22, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27415,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27416,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27417,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27418,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27419,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27420,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27421,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27422,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27423,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27424,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27425,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27426,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27427,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 501.48,,OUTPAT REV HCPCS COMBO 1, 718.33,OTHER, 501.48, 1142.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27428,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27429,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27430,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27431,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27432,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27433,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27434,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27435,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27436,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27437,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27438,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27439,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27440,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27441,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27442,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27443,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27444,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27445,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27446,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27447,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27448,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27449,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27450,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27451,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27452,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27453,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 173.27,,OUTPAT REV HCPCS COMBO 1, 242.39,OTHER, 173.27, 394.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27454,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 173.27,,OUTPAT REV HCPCS COMBO 1, 242.39,OTHER, 173.27, 394.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27455,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27456,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 96.75,,OUTPAT REV HCPCS COMBO 1, 199.77,OTHER, 96.75, 377.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27457,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 96.75,,OUTPAT REV HCPCS COMBO 1, 266.50,OTHER, 96.75, 657.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27458,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1478.34,,OUTPAT REV HCPCS COMBO 1, 2146.91,OTHER, 1478.34, 3369.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27459,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1478.34,,OUTPAT REV HCPCS COMBO 1, 2146.91,OTHER, 1478.34, 3369.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27460,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 482.83,,OUTPAT REV HCPCS COMBO 1, 719.65,OTHER, 482.83, 1100.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27461,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 863.68,,OUTPAT REV HCPCS COMBO 1, 1287.31,OTHER, 863.68, 1968.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27462,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 195.18,,OUTPAT REV HCPCS COMBO 1, 290.91,OTHER, 195.18, 444.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27463,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27464,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 112.28,,OUTPAT REV HCPCS COMBO 1, 162.43,OTHER, 112.28, 255.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27465,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 97.21,,OUTPAT REV HCPCS COMBO 1, 145.32,OTHER, 97.21, 221.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27466,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 62.09,,OUTPAT REV HCPCS COMBO 1, 116.13,OTHER, 62.09, 191.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27467,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 76.24,OTHER, 51.17, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27468,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 91.62,,OUTPAT REV HCPCS COMBO 1, 124.60,OTHER, 86.34, 208.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27469,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27470,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27471,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27472,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 58.91,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27473,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27474,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 161.46,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27475,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27476,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27477,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27478,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 122.45,,OUTPAT REV HCPCS COMBO 1, 171.96,OTHER, 122.45, 279.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27479,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27480,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 94.39,,OUTPAT REV HCPCS COMBO 1, 127.74,OTHER, 86.34, 215.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27481,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27482,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 137.97,,OUTPAT REV HCPCS COMBO 1, 189.58,OTHER, 137.97, 314.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27483,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27484,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 84.85,,OUTPAT REV HCPCS COMBO 1, 116.92,OTHER, 84.85, 193.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27485,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27486,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 234.79,,OUTPAT REV HCPCS COMBO 1, 299.54,OTHER, 138.19, 535.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27487,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27488,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 165.67,,OUTPAT REV HCPCS COMBO 1, 221.04,OTHER, 138.19, 377.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27489,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27490,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 127.28,,OUTPAT REV HCPCS COMBO 1, 177.44,OTHER, 127.28, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27491,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27492,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 44.60,,OUTPAT REV HCPCS COMBO 1, 71.21,OTHER, 44.60, 101.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27493,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27494,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 152.34,,OUTPAT REV HCPCS COMBO 1, 193.56,OTHER, 86.34, 347.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27495,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27496,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 178.71,,OUTPAT REV HCPCS COMBO 1, 223.50,OTHER, 86.34, 407.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27497,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1259.10,,OUTPAT REV HCPCS COMBO 1, 1313.91,OTHER, 283.82, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27498,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 935.89,,OUTPAT REV HCPCS COMBO 1, 1313.91,OTHER, 283.82, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27499,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27500,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27501,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 962.60,,OUTPAT REV HCPCS COMBO 1, 1196.04,OTHER, 432.18, 2193.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27502,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 962.60,,OUTPAT REV HCPCS COMBO 1, 1196.04,OTHER, 432.18, 2193.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27503,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27504,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27505,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1259.10,,OUTPAT REV HCPCS COMBO 1, 1545.39,OTHER, 485.27, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27506,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1259.10,,OUTPAT REV HCPCS COMBO 1, 1545.39,OTHER, 485.27, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27507,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27508,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27509,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 781.62,,OUTPAT REV HCPCS COMBO 1, 955.20,OTHER, 283.82, 1781.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27510,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27511,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 518.18,,OUTPAT REV HCPCS COMBO 1, 691.35,OTHER, 432.18, 1180.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27512,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27513,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 679.40,,OUTPAT REV HCPCS COMBO 1, 887.08,OTHER, 485.27, 1548.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27514,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27515,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 734.01,,OUTPAT REV HCPCS COMBO 1, 901.22,OTHER, 283.82, 1673.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27516,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 734.17,,OUTPAT REV HCPCS COMBO 1, 901.22,OTHER, 283.82, 1673.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27517,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27518,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27519,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 839.22,,OUTPAT REV HCPCS COMBO 1, 1055.93,OTHER, 432.18, 1912.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27520,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1056.51,,OUTPAT REV HCPCS COMBO 1, 1302.68,OTHER, 432.18, 2407.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27521,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27522,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27523,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 350.02,,OUTPAT REV HCPCS COMBO 1, 513.03,OTHER, 350.02, 797.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27524,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27525,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1076.96,,OUTPAT REV HCPCS COMBO 1, 1290.59,OTHER, 283.82, 2454.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27526,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27527,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1120.02,,OUTPAT REV HCPCS COMBO 1, 1374.81,OTHER, 432.18, 2552.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27528,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27529,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1013.04,,OUTPAT REV HCPCS COMBO 1, 1265.96,OTHER, 485.27, 2308.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27530,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27531,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 843.77,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27532,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 843.77,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27533,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 843.77,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27534,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27535,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27536,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27537,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1015.19,,OUTPAT REV HCPCS COMBO 1, 1270.81,OTHER, 495.38, 2313.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27538,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27539,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1317.38,,OUTPAT REV HCPCS COMBO 1, 1681.52,OTHER, 779.04, 3002.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27540,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27541,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 971.97,,OUTPAT REV HCPCS COMBO 1, 1224.87,OTHER, 508.57, 2215.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27542,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27543,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1036.73,,OUTPAT REV HCPCS COMBO 1, 1324.21,OTHER, 616.91, 2362.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27544,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27545,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1186.59,,OUTPAT REV HCPCS COMBO 1, 1532.99,OTHER, 779.04, 2704.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27546,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27547,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 979.65,,OUTPAT REV HCPCS COMBO 1, 1233.59,OTHER, 508.57, 2232.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27548,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27549,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 976.96,,OUTPAT REV HCPCS COMBO 1, 1256.33,OTHER, 616.91, 2226.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27550,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27551,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1123.27,,OUTPAT REV HCPCS COMBO 1, 1461.09,OTHER, 779.04, 2560.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27552,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27553,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1138.21,,OUTPAT REV HCPCS COMBO 1, 1413.66,OTHER, 508.57, 2594.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27554,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27555,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1757.38,,OUTPAT REV HCPCS COMBO 1, 2181.19,OTHER, 779.04, 4005.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27556,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1757.38,,OUTPAT REV HCPCS COMBO 1, 2181.19,OTHER, 779.04, 4005.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27557,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27558,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27559,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27560,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27561,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27562,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27563,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27564,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27565,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27566,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27567,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27568,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27569,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27570,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27571,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27572,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27573,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 195.04,,OUTPAT REV HCPCS COMBO 1, 242.05,OTHER, 86.34, 444.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27574,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 196.33,,OUTPAT REV HCPCS COMBO 1, 243.52,OTHER, 86.34, 447.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27575,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27576,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27577,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 159.59,,OUTPAT REV HCPCS COMBO 1, 214.14,OTHER, 138.19, 363.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27578,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 182.39,,OUTPAT REV HCPCS COMBO 1, 240.03,OTHER, 138.19, 415.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27579,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27580,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27581,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 190.18,,OUTPAT REV HCPCS COMBO 1, 248.87,OTHER, 138.19, 433.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27582,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27583,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 127.28,,OUTPAT REV HCPCS COMBO 1, 165.10,OTHER, 86.34, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27584,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27585,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27586,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27587,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27588,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27589,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27590,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27591,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27592,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1356.87,OTHER, 432.18, 2737.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27593,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1201.21,,OUTPAT REV HCPCS COMBO 1, 1356.87,OTHER, 432.18, 2737.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27594,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27595,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1498.49,,OUTPAT REV HCPCS COMBO 1, 1817.25,OTHER, 485.27, 3415.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27596,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27597,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27598,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27599,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27600,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27601,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27602,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27603,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2141.41,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27604,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27605,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27606,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27607,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27608,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27609,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27610,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27611,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27612,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 544.38,,OUTPAT REV HCPCS COMBO 1, 1310.99,OTHER, 544.38, 2768.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27613,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1214.75,,OUTPAT REV HCPCS COMBO 1, 1310.99,OTHER, 544.38, 2768.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27614,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27615,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27616,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 130.72,,OUTPAT REV HCPCS COMBO 1, 169.01,OTHER, 86.34, 297.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27617,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 130.72,,OUTPAT REV HCPCS COMBO 1, 169.01,OTHER, 86.34, 297.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27618,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27619,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27620,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 189.11,,OUTPAT REV HCPCS COMBO 1, 247.65,OTHER, 138.19, 430.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27621,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27622,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 279.76,,OUTPAT REV HCPCS COMBO 1, 350.60,OTHER, 138.19, 637.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27623,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27624,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 307.96,,OUTPAT REV HCPCS COMBO 1, 382.63,OTHER, 138.19, 701.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27625,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27626,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 229.47,,OUTPAT REV HCPCS COMBO 1, 293.50,OTHER, 138.19, 522.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27627,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27628,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 205.14,,OUTPAT REV HCPCS COMBO 1, 265.86,OTHER, 138.19, 467.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27629,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27630,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 161.46,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27631,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27632,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 107.50,,OUTPAT REV HCPCS COMBO 1, 142.64,OTHER, 86.34, 245.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27633,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27634,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.06,OTHER, 36.98, 88.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27635,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 163.44,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27636,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27637,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 199.31,,OUTPAT REV HCPCS COMBO 1, 259.24,OTHER, 138.19, 454.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27638,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27639,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 118.00,,OUTPAT REV HCPCS COMBO 1, 166.91,OTHER, 118.00, 268.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27640,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27641,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 329.50,,OUTPAT REV HCPCS COMBO 1, 407.08,OTHER, 138.19, 750.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27642,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27643,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1225.59,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27644,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1225.59,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27645,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1225.59,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27646,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27647,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27648,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27649,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 483.75,,OUTPAT REV HCPCS COMBO 1, 664.89,OTHER, 483.75, 1102.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27650,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27651,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1392.67,,OUTPAT REV HCPCS COMBO 1, 1649.11,OTHER, 283.82, 3173.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27652,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1392.67,,OUTPAT REV HCPCS COMBO 1, 1649.11,OTHER, 283.82, 3173.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27653,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27654,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27655,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1376.00,,OUTPAT REV HCPCS COMBO 1, 1665.51,OTHER, 432.18, 3136.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27656,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27657,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1207.81,,OUTPAT REV HCPCS COMBO 1, 1439.18,OTHER, 283.82, 2752.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27658,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27659,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1364.62,,OUTPAT REV HCPCS COMBO 1, 1652.58,OTHER, 432.18, 3110.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27660,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27661,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1290.00,,OUTPAT REV HCPCS COMBO 1, 1580.48,OTHER, 485.27, 2940.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27662,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27663,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1401.19,,OUTPAT REV HCPCS COMBO 1, 1712.29,OTHER, 508.57, 3193.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27664,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27665,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1561.88,,OUTPAT REV HCPCS COMBO 1, 1894.78,OTHER, 508.57, 3559.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27666,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27667,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1370.93,,OUTPAT REV HCPCS COMBO 1, 1677.93,OTHER, 508.57, 3124.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27668,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27669,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1703.32,,OUTPAT REV HCPCS COMBO 1, 2119.80,OTHER, 779.04, 3881.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27670,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27671,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2072.93,,OUTPAT REV HCPCS COMBO 1, 2539.54,OTHER, 779.04, 4724.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27672,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27673,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1941.42,,OUTPAT REV HCPCS COMBO 1, 2390.20,OTHER, 779.04, 4424.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27674,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27675,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27676,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27677,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27678,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 179.56,,OUTPAT REV HCPCS COMBO 1, 236.81,OTHER, 138.19, 409.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27679,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27680,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 141.74,,OUTPAT REV HCPCS COMBO 1, 193.87,OTHER, 138.19, 323.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27681,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27682,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1051.04,,OUTPAT REV HCPCS COMBO 1, 1261.16,OTHER, 283.82, 2395.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27683,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1051.04,,OUTPAT REV HCPCS COMBO 1, 1261.16,OTHER, 283.82, 2395.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27684,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27685,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27686,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1015.49,,OUTPAT REV HCPCS COMBO 1, 1256.10,OTHER, 432.18, 2314.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27687,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27688,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 686.07,,OUTPAT REV HCPCS COMBO 1, 894.65,OTHER, 485.27, 1563.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27689,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27690,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1435.73,,OUTPAT REV HCPCS COMBO 1, 1751.53,OTHER, 508.57, 3272.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27691,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27692,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2152.02,,OUTPAT REV HCPCS COMBO 1, 2629.35,OTHER, 779.04, 4904.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27693,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27694,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27695,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27696,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27697,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27698,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27699,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27700,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 126.48,,OUTPAT REV HCPCS COMBO 1, 164.19,OTHER, 86.34, 288.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27701,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27702,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 179.46,,OUTPAT REV HCPCS COMBO 1, 224.35,OTHER, 86.34, 408.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27703,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27704,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 165.68,,OUTPAT REV HCPCS COMBO 1, 208.71,OTHER, 86.34, 377.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27705,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 165.68,,OUTPAT REV HCPCS COMBO 1, 208.71,OTHER, 86.34, 377.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27706,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 171.85,,OUTPAT REV HCPCS COMBO 1, 215.71,OTHER, 86.34, 391.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27707,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27708,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27709,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27710,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27711,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27712,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 113.20,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27713,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27714,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27715,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27716,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 136.74,,OUTPAT REV HCPCS COMBO 1, 175.84,OTHER, 86.34, 311.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27717,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 130.77,,OUTPAT REV HCPCS COMBO 1, 169.06,OTHER, 86.34, 298.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27718,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 130.77,,OUTPAT REV HCPCS COMBO 1, 169.06,OTHER, 86.34, 298.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27719,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27720,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27721,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27722,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 178.02,,OUTPAT REV HCPCS COMBO 1, 235.06,OTHER, 138.19, 405.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27723,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 178.02,,OUTPAT REV HCPCS COMBO 1, 235.06,OTHER, 138.19, 405.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27724,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 182.68,,OUTPAT REV HCPCS COMBO 1, 240.36,OTHER, 138.19, 416.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27725,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27726,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27727,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27728,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 175.36,,OUTPAT REV HCPCS COMBO 1, 219.70,OTHER, 86.34, 399.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27729,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 170.74,,OUTPAT REV HCPCS COMBO 1, 214.45,OTHER, 86.34, 389.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27730,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 170.74,,OUTPAT REV HCPCS COMBO 1, 214.45,OTHER, 86.34, 389.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27731,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27732,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27733,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27734,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 163.79,,OUTPAT REV HCPCS COMBO 1, 206.56,OTHER, 86.34, 373.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27735,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 168.41,,OUTPAT REV HCPCS COMBO 1, 211.81,OTHER, 86.34, 383.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27736,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 163.79,,OUTPAT REV HCPCS COMBO 1, 206.56,OTHER, 86.34, 373.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27737,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27738,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27739,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27740,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 184.47,,OUTPAT REV HCPCS COMBO 1, 230.04,OTHER, 86.34, 420.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27741,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 178.71,,OUTPAT REV HCPCS COMBO 1, 223.50,OTHER, 86.34, 407.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27742,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27743,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27744,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27745,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 185.16,,OUTPAT REV HCPCS COMBO 1, 230.83,OTHER, 86.34, 421.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27746,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 185.16,,OUTPAT REV HCPCS COMBO 1, 230.83,OTHER, 86.34, 421.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27747,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 190.92,,OUTPAT REV HCPCS COMBO 1, 237.37,OTHER, 86.34, 435.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27748,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27749,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27750,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27751,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 58.91,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27752,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 81.70,,OUTPAT REV HCPCS COMBO 1, 125.68,OTHER, 81.70, 186.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27753,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 58.91,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27754,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27755,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27756,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27757,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 170.11,,OUTPAT REV HCPCS COMBO 1, 213.73,OTHER, 86.34, 387.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27758,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 164.82,,OUTPAT REV HCPCS COMBO 1, 207.73,OTHER, 86.34, 375.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27759,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 164.83,,OUTPAT REV HCPCS COMBO 1, 207.74,OTHER, 86.34, 375.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27760,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27761,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27762,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27763,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 191.64,,OUTPAT REV HCPCS COMBO 1, 238.18,OTHER, 86.34, 436.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27764,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 196.26,,OUTPAT REV HCPCS COMBO 1, 243.44,OTHER, 86.34, 447.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27765,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 191.64,,OUTPAT REV HCPCS COMBO 1, 238.18,OTHER, 86.34, 436.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27766,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27767,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27768,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27769,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 181.03,,OUTPAT REV HCPCS COMBO 1, 238.48,OTHER, 138.19, 412.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27770,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 175.27,,OUTPAT REV HCPCS COMBO 1, 231.94,OTHER, 138.19, 399.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27771,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 175.27,,OUTPAT REV HCPCS COMBO 1, 231.94,OTHER, 138.19, 399.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27772,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27773,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27774,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27775,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 175.94,,OUTPAT REV HCPCS COMBO 1, 220.36,OTHER, 86.34, 400.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27776,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 175.99,,OUTPAT REV HCPCS COMBO 1, 220.42,OTHER, 86.34, 401.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27777,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 180.62,,OUTPAT REV HCPCS COMBO 1, 225.67,OTHER, 86.34, 411.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27778,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27779,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27780,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27781,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 146.59,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27782,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 135.73,,OUTPAT REV HCPCS COMBO 1, 174.69,OTHER, 86.34, 309.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27783,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27784,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27785,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27786,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27787,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27788,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27789,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27790,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27791,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27792,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27793,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27794,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27795,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27796,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27797,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27798,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27799,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27800,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27801,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27802,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27803,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27804,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27805,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27806,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27807,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 813.42,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27808,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 1061.06,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27809,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27810,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27811,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27812,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27813,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27814,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 287.67,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27815,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 287.67,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27816,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27817,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27818,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 287.67,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27819,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27820,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27821,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 813.42,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27822,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27823,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27824,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27825,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27826,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27827,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27828,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27829,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27830,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27831,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27832,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27833,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27834,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27835,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27836,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1216.47,,OUTPAT REV HCPCS COMBO 1, 1484.34,OTHER, 432.18, 2772.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27837,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1216.47,,OUTPAT REV HCPCS COMBO 1, 1484.34,OTHER, 432.18, 2772.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27838,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27839,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27840,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27841,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27842,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27843,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27844,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27845,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 822.87,,OUTPAT REV HCPCS COMBO 1, 1055.55,OTHER, 508.57, 1875.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27846,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27847,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1419.11,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27848,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1419.11,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27849,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1419.11,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27850,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27851,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27852,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27853,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27854,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27855,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27856,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27857,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27858,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27859,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27860,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27861,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27862,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27863,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27864,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27865,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27866,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27867,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27868,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27869,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27870,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27871,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27872,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27873,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27874,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27875,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27876,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27877,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27878,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27879,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27880,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27881,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27882,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27883,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27884,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27885,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1113.81,,OUTPAT REV HCPCS COMBO 1, 1450.34,OTHER, 779.04, 2538.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27886,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1113.81,,OUTPAT REV HCPCS COMBO 1, 1450.34,OTHER, 779.04, 2538.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27887,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27888,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27889,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27890,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27891,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27892,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27893,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 154.92,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27894,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 154.92,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27895,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 154.92,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27896,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27897,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27898,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27899,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27900,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27901,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27902,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27903,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27904,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27905,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27906,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27907,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27908,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 195.73,,OUTPAT REV HCPCS COMBO 1, 234.40,OTHER, 146.51, 446.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27909,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 155.65,,OUTPAT REV HCPCS COMBO 1, 234.40,OTHER, 146.51, 446.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27910,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27911,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27912,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 160.19,,OUTPAT REV HCPCS COMBO 1, 202.98,OTHER, 88.46, 365.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27913,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 160.19,,OUTPAT REV HCPCS COMBO 1, 202.98,OTHER, 88.46, 365.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27914,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 164.81,,OUTPAT REV HCPCS COMBO 1, 208.23,OTHER, 88.46, 375.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27915,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27916,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27917,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27918,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 167.46,,OUTPAT REV HCPCS COMBO 1, 210.73,OTHER, 86.34, 381.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27919,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 162.18,,OUTPAT REV HCPCS COMBO 1, 204.73,OTHER, 86.34, 369.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27920,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 162.18,,OUTPAT REV HCPCS COMBO 1, 204.73,OTHER, 86.34, 369.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27921,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27922,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27923,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27924,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 208.05,,OUTPAT REV HCPCS COMBO 1, 269.16,OTHER, 138.19, 474.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27925,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 212.67,,OUTPAT REV HCPCS COMBO 1, 274.41,OTHER, 138.19, 484.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27926,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 208.05,,OUTPAT REV HCPCS COMBO 1, 269.16,OTHER, 138.19, 474.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27927,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27928,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27929,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27930,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 325.08,,OUTPAT REV HCPCS COMBO 1, 402.07,OTHER, 138.19, 740.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27931,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 319.17,,OUTPAT REV HCPCS COMBO 1, 395.36,OTHER, 138.19, 727.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27932,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 319.17,,OUTPAT REV HCPCS COMBO 1, 395.36,OTHER, 138.19, 727.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27933,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27934,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27935,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27936,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 116.95,,OUTPAT REV HCPCS COMBO 1, 153.37,OTHER, 86.34, 266.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27937,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27938,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 195.94,,OUTPAT REV HCPCS COMBO 1, 243.07,OTHER, 86.34, 446.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27939,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 191.32,,OUTPAT REV HCPCS COMBO 1, 237.82,OTHER, 86.34, 436.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27940,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 191.32,,OUTPAT REV HCPCS COMBO 1, 237.82,OTHER, 86.34, 436.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27941,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27942,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27943,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27944,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 74.90,OTHER, 36.98, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27945,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 74.90,OTHER, 36.98, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27946,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 73.96,,OUTPAT REV HCPCS COMBO 1, 116.89,OTHER, 73.96, 168.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27947,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27948,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27949,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27950,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 163.83,,OUTPAT REV HCPCS COMBO 1, 218.95,OTHER, 138.19, 373.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27951,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 163.83,,OUTPAT REV HCPCS COMBO 1, 218.95,OTHER, 138.19, 373.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27952,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 169.42,,OUTPAT REV HCPCS COMBO 1, 225.30,OTHER, 138.19, 386.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27953,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27954,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27955,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27956,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 185.33,,OUTPAT REV HCPCS COMBO 1, 243.37,OTHER, 138.19, 422.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27957,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 179.52,,OUTPAT REV HCPCS COMBO 1, 236.76,OTHER, 138.19, 409.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27958,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 179.52,,OUTPAT REV HCPCS COMBO 1, 236.76,OTHER, 138.19, 409.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27959,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27960,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27961,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27962,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 146.18,,OUTPAT REV HCPCS COMBO 1, 186.56,OTHER, 86.34, 333.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27963,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 146.18,,OUTPAT REV HCPCS COMBO 1, 186.56,OTHER, 86.34, 333.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27964,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27965,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27966,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 202.21,,OUTPAT REV HCPCS COMBO 1, 250.19,OTHER, 86.34, 460.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27967,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 197.50,,OUTPAT REV HCPCS COMBO 1, 244.84,OTHER, 86.34, 450.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27968,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 197.59,,OUTPAT REV HCPCS COMBO 1, 244.94,OTHER, 86.34, 450.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27969,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27970,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27971,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27972,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 100.19,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27973,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 100.19,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27974,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 100.19,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27975,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27976,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27977,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27978,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27979,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27980,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27981,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27982,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27983,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27984,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27985,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27986,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 139.75,,OUTPAT REV HCPCS COMBO 1, 179.26,OTHER, 86.34, 318.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27987,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27988,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 27989,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27990,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27991,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27992,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27993,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27994,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27995,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27996,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27997,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27998,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 27999,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28000,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28001,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28002,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28003,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 991.15,,OUTPAT REV HCPCS COMBO 1, 1193.14,OTHER, 283.82, 2258.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28004,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28005,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28006,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28007,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28008,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28009,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28010,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28011,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28012,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28013,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28014,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28015,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28016,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28017,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28018,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28019,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28020,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28021,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28022,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28023,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28024,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28025,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28026,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28027,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28028,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1173.04,,OUTPAT REV HCPCS COMBO 1, 1435.02,OTHER, 432.18, 2673.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28029,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1167.20,,OUTPAT REV HCPCS COMBO 1, 1428.39,OTHER, 432.18, 2660.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28030,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1167.20,,OUTPAT REV HCPCS COMBO 1, 1428.39,OTHER, 432.18, 2660.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28031,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28032,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28033,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28034,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28035,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28036,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28037,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28038,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28039,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28040,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 597.27,,OUTPAT REV HCPCS COMBO 1, 796.22,OTHER, 495.38, 1361.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28041,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 597.27,,OUTPAT REV HCPCS COMBO 1, 796.22,OTHER, 495.38, 1361.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28042,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28043,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28044,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28045,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28046,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28047,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28048,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28049,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28050,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28051,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28052,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28053,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28054,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28055,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28056,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1556.76,,OUTPAT REV HCPCS COMBO 1, 1953.37,OTHER, 779.04, 3547.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28057,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1556.76,,OUTPAT REV HCPCS COMBO 1, 1953.37,OTHER, 779.04, 3547.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28058,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28059,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28060,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28061,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28062,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1356.11,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28063,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1356.11,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28064,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28065,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28066,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28067,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28068,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28069,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28070,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28071,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28072,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28073,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28074,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28075,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28076,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28077,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28078,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28079,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28080,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28081,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28082,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28083,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28084,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28085,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28086,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28087,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28088,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28089,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28090,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1227.35,OTHER, 786.90, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28091,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1323.48,OTHER, 786.90, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28092,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1474.10,OTHER, 989.00, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28093,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 786.90,,OUTPAT REV HCPCS COMBO 1, 1227.35,OTHER, 786.90, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28094,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 786.90,,OUTPAT REV HCPCS COMBO 1, 1323.48,OTHER, 786.90, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28095,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28096,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28097,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28098,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28099,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28100,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 71.38,,OUTPAT REV HCPCS COMBO 1, 102.58,OTHER, 71.38, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28101,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 71.38,,OUTPAT REV HCPCS COMBO 1, 102.58,OTHER, 71.38, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28102,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28103,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28104,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 83.13,OTHER, 36.98, 172.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28105,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28106,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 254.96,,OUTPAT REV HCPCS COMBO 1, 322.43,OTHER, 138.19, 581.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28107,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 254.96,,OUTPAT REV HCPCS COMBO 1, 322.43,OTHER, 138.19, 581.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28108,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28109,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28110,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1125.78,,OUTPAT REV HCPCS COMBO 1, 1346.03,OTHER, 283.82, 2565.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28111,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28112,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1269.20,,OUTPAT REV HCPCS COMBO 1, 1544.22,OTHER, 432.18, 2892.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28113,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28114,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1433.28,,OUTPAT REV HCPCS COMBO 1, 1743.20,OTHER, 485.27, 3266.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28115,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28116,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2571.41,,OUTPAT REV HCPCS COMBO 1, 3113.75,OTHER, 813.20, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28117,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28118,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1431.39,,OUTPAT REV HCPCS COMBO 1, 1743.46,OTHER, 495.38, 3262.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28119,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28120,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2239.96,,OUTPAT REV HCPCS COMBO 1, 2609.45,OTHER, 276.02, 5105.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28121,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2239.96,,OUTPAT REV HCPCS COMBO 1, 2609.45,OTHER, 276.02, 5105.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28122,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28123,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28124,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2571.41,,OUTPAT REV HCPCS COMBO 1, 3021.78,OTHER, 426.91, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28125,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2571.41,,OUTPAT REV HCPCS COMBO 1, 3021.78,OTHER, 426.91, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28126,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28127,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28128,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2881.09,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28129,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2881.09,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28130,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2881.09,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28131,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28132,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28133,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28134,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1381.27,,OUTPAT REV HCPCS COMBO 1, 1689.68,OTHER, 508.57, 3148.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28135,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1381.27,,OUTPAT REV HCPCS COMBO 1, 1689.68,OTHER, 508.57, 3148.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28136,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28137,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28138,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1454.34,,OUTPAT REV HCPCS COMBO 1, 1837.06,OTHER, 779.04, 3314.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28139,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28140,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1075.00,,OUTPAT REV HCPCS COMBO 1, 2098.35,OTHER, 1075.00, 3967.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28141,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1740.64,,OUTPAT REV HCPCS COMBO 1, 2098.35,OTHER, 1075.00, 3967.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28142,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28143,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28144,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28145,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 300.14,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28146,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 300.14,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28147,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 300.14,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28148,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28149,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28150,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 472.37,,OUTPAT REV HCPCS COMBO 1, 704.06,OTHER, 472.37, 1076.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28151,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28152,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 166.15,,OUTPAT REV HCPCS COMBO 1, 248.14,OTHER, 166.15, 378.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28153,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28154,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 326.19,,OUTPAT REV HCPCS COMBO 1, 429.88,OTHER, 249.71, 743.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28155,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28156,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1213.11,,OUTPAT REV HCPCS COMBO 1, 1495.57,OTHER, 495.38, 2764.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28157,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1213.11,,OUTPAT REV HCPCS COMBO 1, 1495.57,OTHER, 495.38, 2764.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28158,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28159,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28160,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 150.50,,OUTPAT REV HCPCS COMBO 1, 224.32,OTHER, 150.50, 343.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28161,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28162,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 309.81,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28163,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 309.81,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28164,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 309.81,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28165,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28166,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28167,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28168,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 233.31,,OUTPAT REV HCPCS COMBO 1, 286.59,OTHER, 90.89, 531.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28169,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28170,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 219.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28171,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 219.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28172,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 219.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28173,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 225.75,,OUTPAT REV HCPCS COMBO 1, 288.12,OTHER, 133.37, 514.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28174,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28175,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28176,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28177,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28178,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 413.68,,OUTPAT REV HCPCS COMBO 1, 503.49,OTHER, 141.55, 942.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28179,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28180,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28181,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28182,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28183,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28184,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28185,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28186,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28187,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28188,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28189,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28190,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 377.80,,OUTPAT REV HCPCS COMBO 1, 468.07,OTHER, 163.97, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28191,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28192,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28193,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28194,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28195,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28196,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 335.33,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28197,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28198,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28199,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28200,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28201,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28202,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 335.33,,OUTPAT REV HCPCS COMBO 1, 414.50,OTHER, 141.55, 764.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28203,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28204,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 161.25,,OUTPAT REV HCPCS COMBO 1, 214.87,OTHER, 133.37, 367.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28205,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28206,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 330.24,,OUTPAT REV HCPCS COMBO 1, 408.73,OTHER, 141.55, 752.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28207,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28208,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 417.26,,OUTPAT REV HCPCS COMBO 1, 507.55,OTHER, 141.55, 950.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28209,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28210,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 663.92,,OUTPAT REV HCPCS COMBO 1, 775.60,OTHER, 90.89, 1513.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28211,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28212,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 227.90,,OUTPAT REV HCPCS COMBO 1, 290.56,OTHER, 133.37, 519.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28213,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28214,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 339.97,,OUTPAT REV HCPCS COMBO 1, 419.77,OTHER, 141.55, 774.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28215,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28216,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 385.59,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28217,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 385.59,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28218,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 385.59,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28219,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28220,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28221,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28222,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 269.07,,OUTPAT REV HCPCS COMBO 1, 322.12,OTHER, 90.89, 613.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28223,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 260.12,,OUTPAT REV HCPCS COMBO 1, 322.12,OTHER, 90.89, 613.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28224,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28225,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28226,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 330.02,,OUTPAT REV HCPCS COMBO 1, 408.48,OTHER, 141.55, 752.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28227,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28228,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 688.00,,OUTPAT REV HCPCS COMBO 1, 813.95,OTHER, 137.10, 1568.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28229,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 435.01,,OUTPAT REV HCPCS COMBO 1, 526.64,OTHER, 137.10, 991.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28230,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 435.01,,OUTPAT REV HCPCS COMBO 1, 526.64,OTHER, 137.10, 991.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28231,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28232,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28233,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28234,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28235,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 236.50,,OUTPAT REV HCPCS COMBO 1, 300.33,OTHER, 133.37, 539.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28236,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28237,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28238,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28239,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28240,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28241,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28242,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28243,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28244,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28245,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28246,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28247,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28248,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28249,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28250,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28251,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28252,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 285.90,,OUTPAT REV HCPCS COMBO 1, 426.14,OTHER, 285.90, 651.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28253,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28254,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 182.57,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28255,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 182.57,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28256,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 182.57,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28257,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28258,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28259,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28260,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28261,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 186.51,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28262,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 186.51,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28263,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 61.06,,OUTPAT REV HCPCS COMBO 1, 91.01,OTHER, 61.06, 139.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28264,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 21.15,,OUTPAT REV HCPCS COMBO 1, 78.82,OTHER, 21.15, 181.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28265,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28266,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28267,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28268,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28269,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28270,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28271,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28272,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28273,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 210.70,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28274,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 175.87,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28275,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 210.70,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28276,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28277,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28278,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28279,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28280,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28281,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28282,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28283,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28284,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 81.44,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28285,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28286,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28287,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28288,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28289,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28290,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28291,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28292,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 73.53,,OUTPAT REV HCPCS COMBO 1, 116.40,OTHER, 73.53, 167.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28293,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28294,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 315.98,,OUTPAT REV HCPCS COMBO 1, 414.07,OTHER, 232.03, 720.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28295,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 84.28,,OUTPAT REV HCPCS COMBO 1, 158.67,OTHER, 84.28, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28296,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 150.93,,OUTPAT REV HCPCS COMBO 1, 158.67,OTHER, 84.28, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28297,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28298,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28299,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 127.28,,OUTPAT REV HCPCS COMBO 1, 154.63,OTHER, 42.36, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28300,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 150.93,,OUTPAT REV HCPCS COMBO 1, 204.30,OTHER, 138.19, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28301,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28302,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 549.04,,OUTPAT REV HCPCS COMBO 1, 660.83,OTHER, 156.82, 1251.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28303,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 549.04,,OUTPAT REV HCPCS COMBO 1, 660.83,OTHER, 156.82, 1251.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28304,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28305,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28306,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 426.80,,OUTPAT REV HCPCS COMBO 1, 533.81,OTHER, 206.35, 972.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28307,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 426.80,,OUTPAT REV HCPCS COMBO 1, 533.81,OTHER, 206.35, 972.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28308,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28309,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28310,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 600.24,,OUTPAT REV HCPCS COMBO 1, 757.92,OTHER, 320.35, 1367.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28311,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28312,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 724.72,,OUTPAT REV HCPCS COMBO 1, 899.81,OTHER, 322.62, 1651.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28313,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28314,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 847.10,,OUTPAT REV HCPCS COMBO 1, 1092.65,OTHER, 548.80, 1930.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28315,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28316,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 672.15,,OUTPAT REV HCPCS COMBO 1, 864.03,OTHER, 423.08, 1531.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28317,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28318,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 215.00,,OUTPAT REV HCPCS COMBO 1, 344.89,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28319,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28320,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 645.00,,OUTPAT REV HCPCS COMBO 1, 830.31,OTHER, 410.92, 1470.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28321,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28322,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 885.80,,OUTPAT REV HCPCS COMBO 1, 1103.77,OTHER, 410.92, 2018.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28323,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28324,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1111.16,OTHER, 359.95, 2058.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28325,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28326,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 474.08,,OUTPAT REV HCPCS COMBO 1, 624.07,OTHER, 359.95, 1080.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28327,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28328,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 516.57,,OUTPAT REV HCPCS COMBO 1, 672.34,OTHER, 360.01, 1177.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28329,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28330,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 417.10,,OUTPAT REV HCPCS COMBO 1, 559.38,OTHER, 360.01, 950.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28331,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28332,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1005.92,,OUTPAT REV HCPCS COMBO 1, 1228.06,OTHER, 360.01, 2292.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28333,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28334,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1064.04,,OUTPAT REV HCPCS COMBO 1, 1294.05,OTHER, 360.01, 2425.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28335,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28336,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 470.85,,OUTPAT REV HCPCS COMBO 1, 701.80,OTHER, 470.85, 1073.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28337,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28338,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 775.51,,OUTPAT REV HCPCS COMBO 1, 1149.19,OTHER, 775.51, 1767.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28339,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 775.51,,OUTPAT REV HCPCS COMBO 1, 1149.19,OTHER, 775.51, 1767.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28340,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28341,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28342,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1760.54,,OUTPAT REV HCPCS COMBO 1, 2267.81,OTHER, 1127.76, 4012.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28343,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28344,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 624.40,,OUTPAT REV HCPCS COMBO 1, 815.01,OTHER, 444.92, 1423.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28345,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 624.40,,OUTPAT REV HCPCS COMBO 1, 815.01,OTHER, 444.92, 1423.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28346,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28347,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28348,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 500.41,,OUTPAT REV HCPCS COMBO 1, 635.79,OTHER, 283.54, 1140.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28349,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28350,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 803.60,,OUTPAT REV HCPCS COMBO 1, 984.09,OTHER, 300.36, 1831.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28351,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28352,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 831.76,,OUTPAT REV HCPCS COMBO 1, 1050.06,OTHER, 443.12, 1895.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28353,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28354,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 447.20,,OUTPAT REV HCPCS COMBO 1, 684.67,OTHER, 447.20, 1019.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28355,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28356,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2048.52,,OUTPAT REV HCPCS COMBO 1, 2685.69,OTHER, 1509.32, 4668.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28357,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28358,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2121.62,,OUTPAT REV HCPCS COMBO 1, 2768.70,OTHER, 1509.32, 4835.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28359,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 28360,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 26.05,,OUTPAT REV HCPCS COMBO 1, 34.30,OTHER, 19.78, 59.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28361,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 26.05,,OUTPAT REV HCPCS COMBO 1, 32.49,OTHER, 12.18, 59.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28362,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 267.46,,OUTPAT REV HCPCS COMBO 1, 398.65,OTHER, 267.46, 609.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28363,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 60.14,,OUTPAT REV HCPCS COMBO 1, 70.69,OTHER, 10.09, 137.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28364,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 104.38,,OUTPAT REV HCPCS COMBO 1, 122.16,OTHER, 15.20, 237.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28365,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 81.90,,OUTPAT REV HCPCS COMBO 1, 97.60,OTHER, 19.28, 186.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28366,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 81.90,,OUTPAT REV HCPCS COMBO 1, 97.60,OTHER, 19.28, 186.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28367,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 70.95,,OUTPAT REV HCPCS COMBO 1, 83.55,OTHER, 12.50, 161.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28368,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 70.95,,OUTPAT REV HCPCS COMBO 1, 83.55,OTHER, 12.50, 161.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28369,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 122.86,,OUTPAT REV HCPCS COMBO 1, 155.85,OTHER, 68.59, 280.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28370,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 67.08,,OUTPAT REV HCPCS COMBO 1, 78.98,OTHER, 11.76, 152.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28371,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 56.33,,OUTPAT REV HCPCS COMBO 1, 69.30,OTHER, 22.37, 128.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28372,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 192.21,,OUTPAT REV HCPCS COMBO 1, 229.30,OTHER, 46.28, 438.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28373,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 75.79,,OUTPAT REV HCPCS COMBO 1, 88.95,OTHER, 20.98, 172.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28374,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 72.07,,OUTPAT REV HCPCS COMBO 1, 88.95,OTHER, 20.98, 172.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28375,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 53.39,OTHER, 19.13, 98.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28376,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 53.39,OTHER, 19.13, 98.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28377,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 66.51,,OUTPAT REV HCPCS COMBO 1, 80.17,OTHER, 19.50, 151.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28378,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 41.55,,OUTPAT REV HCPCS COMBO 1, 54.61,OTHER, 31.20, 94.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28379,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 66.47,,OUTPAT REV HCPCS COMBO 1, 80.03,OTHER, 19.08, 151.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28380,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.72,,OUTPAT REV HCPCS COMBO 1, 79.17,OTHER, 19.08, 149.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28381,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 54.32,,OUTPAT REV HCPCS COMBO 1, 63.95,OTHER, 9.52, 123.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28382,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 20.21,,OUTPAT REV HCPCS COMBO 1, 28.28,OTHER, 20.21, 46.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28383,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 69.69,,OUTPAT REV HCPCS COMBO 1, 83.69,OTHER, 19.08, 158.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28384,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 42.46,,OUTPAT REV HCPCS COMBO 1, 53.47,OTHER, 22.03, 96.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28385,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 66.28,,OUTPAT REV HCPCS COMBO 1, 79.81,OTHER, 19.08, 151.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28386,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 35.17,,OUTPAT REV HCPCS COMBO 1, 44.64,OTHER, 19.78, 80.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28387,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 124.34,,OUTPAT REV HCPCS COMBO 1, 145.91,OTHER, 19.78, 283.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28388,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 52.76,,OUTPAT REV HCPCS COMBO 1, 64.76,OTHER, 20.36, 120.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28389,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 103.25,,OUTPAT REV HCPCS COMBO 1, 121.34,OTHER, 17.16, 235.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28390,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 70.55,,OUTPAT REV HCPCS COMBO 1, 84.76,OTHER, 19.50, 160.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28391,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 111.79,,OUTPAT REV HCPCS COMBO 1, 134.69,OTHER, 32.53, 254.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28392,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 74.42,,OUTPAT REV HCPCS COMBO 1, 90.91,OTHER, 26.84, 169.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28393,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 81.85,,OUTPAT REV HCPCS COMBO 1, 56.90,OTHER, 10.75, 186.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28394,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 56.90,OTHER, 10.75, 186.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28395,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 17.20,,OUTPAT REV HCPCS COMBO 1, 23.85,OTHER, 17.20, 39.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28396,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 17.20,,OUTPAT REV HCPCS COMBO 1, 23.85,OTHER, 17.20, 39.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28397,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 112.61,,OUTPAT REV HCPCS COMBO 1, 178.46,OTHER, 112.61, 289.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28398,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 126.85,,OUTPAT REV HCPCS COMBO 1, 178.46,OTHER, 112.61, 289.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28399,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 72.67,,OUTPAT REV HCPCS COMBO 1, 108.31,OTHER, 72.67, 165.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28400,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 64.50,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28401,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.68,,OUTPAT REV HCPCS COMBO 1, 48.71,OTHER, 32.68, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28402,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 120.73,,OUTPAT REV HCPCS COMBO 1, 179.95,OTHER, 120.73, 275.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28403,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 76.91,,OUTPAT REV HCPCS COMBO 1, 114.63,OTHER, 76.91, 175.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28404,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 17.56,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28405,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28406,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 17.56,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28407,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 17.56,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28408,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 60.63,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28409,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.53,,OUTPAT REV HCPCS COMBO 1, 67.87,OTHER, 45.53, 103.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28410,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 68.37,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28411,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 68.37,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28412,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 68.37,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28413,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 58.05,,OUTPAT REV HCPCS COMBO 1, 86.52,OTHER, 58.05, 132.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28414,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 120.81,OTHER, 36.98, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28415,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 125.13,,OUTPAT REV HCPCS COMBO 1, 120.81,OTHER, 36.98, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28416,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 29.76,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28417,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 29.76,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28418,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 29.76,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28419,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 17.75,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28420,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 17.75,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28421,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 17.75,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28422,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 5.59,,OUTPAT REV HCPCS COMBO 1, 7.12,OTHER, 3.24, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28423,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 8.07,OTHER, 3.12, 14.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28424,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 27.22,,OUTPAT REV HCPCS COMBO 1, 33.86,OTHER, 12.40, 62.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28425,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 27.22,,OUTPAT REV HCPCS COMBO 1, 33.86,OTHER, 12.40, 62.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28426,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 64.07,,OUTPAT REV HCPCS COMBO 1, 75.71,OTHER, 12.40, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28427,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 64.07,,OUTPAT REV HCPCS COMBO 1, 75.71,OTHER, 12.40, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28428,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 106.06,,OUTPAT REV HCPCS COMBO 1, 145.60,OTHER, 105.66, 241.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28429,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 106.06,,OUTPAT REV HCPCS COMBO 1, 145.60,OTHER, 105.66, 241.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28430,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 211.56,,OUTPAT REV HCPCS COMBO 1, 262.66,OTHER, 94.12, 482.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28431,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 350.08,,OUTPAT REV HCPCS COMBO 1, 428.98,OTHER, 131.99, 797.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28432,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 87.01,,OUTPAT REV HCPCS COMBO 1, 129.68,OTHER, 87.01, 198.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28433,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 164.26,,OUTPAT REV HCPCS COMBO 1, 244.83,OTHER, 164.26, 374.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28434,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 164.26,,OUTPAT REV HCPCS COMBO 1, 244.83,OTHER, 164.26, 374.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28435,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.44,,OUTPAT REV HCPCS COMBO 1, 53.15,OTHER, 6.50, 103.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28436,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 31.79,,OUTPAT REV HCPCS COMBO 1, 38.90,OTHER, 11.76, 72.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28437,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 117.64,,OUTPAT REV HCPCS COMBO 1, 146.83,OTHER, 55.61, 268.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28438,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 16.23,,OUTPAT REV HCPCS COMBO 1, 20.13,OTHER, 7.13, 37.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28439,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 16.23,,OUTPAT REV HCPCS COMBO 1, 20.13,OTHER, 7.13, 37.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28440,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 23.11,,OUTPAT REV HCPCS COMBO 1, 28.92,OTHER, 11.21, 52.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28441,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 23.11,,OUTPAT REV HCPCS COMBO 1, 28.92,OTHER, 11.21, 52.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28442,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 51.60,,OUTPAT REV HCPCS COMBO 1, 60.58,OTHER, 8.33, 117.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28443,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 51.60,,OUTPAT REV HCPCS COMBO 1, 60.58,OTHER, 8.33, 117.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28444,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 41.87,,OUTPAT REV HCPCS COMBO 1, 50.88,OTHER, 13.98, 95.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28445,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 58.52,,OUTPAT REV HCPCS COMBO 1, 71.06,OTHER, 19.36, 133.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28446,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 92.38,,OUTPAT REV HCPCS COMBO 1, 109.86,OTHER, 20.82, 210.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28447,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.53,,OUTPAT REV HCPCS COMBO 1, 80.16,OTHER, 24.14, 149.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28448,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.53,,OUTPAT REV HCPCS COMBO 1, 80.16,OTHER, 24.14, 149.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28449,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 63.10,OTHER, 20.98, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28450,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 63.10,OTHER, 20.98, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28451,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 42.77,,OUTPAT REV HCPCS COMBO 1, 50.79,OTHER, 9.34, 97.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28452,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 42.77,,OUTPAT REV HCPCS COMBO 1, 50.79,OTHER, 9.34, 97.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28453,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 79.55,,OUTPAT REV HCPCS COMBO 1, 100.38,OTHER, 42.16, 181.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28454,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 97.65,,OUTPAT REV HCPCS COMBO 1, 121.92,OTHER, 46.34, 222.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28455,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 37.84,,OUTPAT REV HCPCS COMBO 1, 50.20,OTHER, 30.37, 86.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28456,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 96.70,,OUTPAT REV HCPCS COMBO 1, 116.31,OTHER, 27.31, 220.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28457,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 40.85,,OUTPAT REV HCPCS COMBO 1, 49.78,OTHER, 14.24, 93.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28458,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 50.98,,OUTPAT REV HCPCS COMBO 1, 63.44,OTHER, 23.30, 116.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28459,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 30.50,,OUTPAT REV HCPCS COMBO 1, 36.36,OTHER, 7.22, 69.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28460,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 30.50,,OUTPAT REV HCPCS COMBO 1, 36.36,OTHER, 7.22, 69.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28461,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 27.61,,OUTPAT REV HCPCS COMBO 1, 33.07,OTHER, 7.22, 62.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28462,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 15.70,,OUTPAT REV HCPCS COMBO 1, 19.33,OTHER, 6.31, 35.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28463,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.02,,OUTPAT REV HCPCS COMBO 1, 33.34,OTHER, 6.38, 63.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28464,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 56.73,OTHER, 22.92, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28465,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 100.38,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28466,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 107.07,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28467,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 100.38,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28468,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 100.80,,OUTPAT REV HCPCS COMBO 1, 123.66,OTHER, 38.58, 229.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28469,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.45,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28470,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.45,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28471,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.45,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28472,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 56.84,,OUTPAT REV HCPCS COMBO 1, 69.24,OTHER, 19.70, 129.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28473,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 42.18,,OUTPAT REV HCPCS COMBO 1, 49.97,OTHER, 8.69, 96.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28474,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 35.26,,OUTPAT REV HCPCS COMBO 1, 44.47,OTHER, 18.58, 80.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28475,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 53.64,,OUTPAT REV HCPCS COMBO 1, 65.14,OTHER, 17.74, 122.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28476,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 71.10,,OUTPAT REV HCPCS COMBO 1, 87.25,OTHER, 27.30, 162.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28477,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 71.10,,OUTPAT REV HCPCS COMBO 1, 87.25,OTHER, 27.30, 162.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28478,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 46.87,,OUTPAT REV HCPCS COMBO 1, 59.01,OTHER, 24.29, 106.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28479,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 104.53,,OUTPAT REV HCPCS COMBO 1, 127.93,OTHER, 36.36, 240.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28480,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 105.53,,OUTPAT REV HCPCS COMBO 1, 127.93,OTHER, 36.36, 240.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28481,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.46,OTHER, 15.47, 105.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28482,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 10.32,,OUTPAT REV HCPCS COMBO 1, 13.69,OTHER, 8.28, 23.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28483,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 61.16,,OUTPAT REV HCPCS COMBO 1, 73.71,OTHER, 17.87, 139.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28484,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 72.21,,OUTPAT REV HCPCS COMBO 1, 87.73,OTHER, 24.06, 164.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28485,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 72.21,,OUTPAT REV HCPCS COMBO 1, 87.73,OTHER, 24.06, 164.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28486,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 53.47,,OUTPAT REV HCPCS COMBO 1, 66.31,OTHER, 23.47, 121.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28487,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 53.47,,OUTPAT REV HCPCS COMBO 1, 66.31,OTHER, 23.47, 121.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28488,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 160.20,,OUTPAT REV HCPCS COMBO 1, 190.19,OTHER, 34.69, 365.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28489,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 181.18,,OUTPAT REV HCPCS COMBO 1, 214.01,OTHER, 34.69, 412.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28490,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 39.85,,OUTPAT REV HCPCS COMBO 1, 47.49,OTHER, 9.37, 90.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28491,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 39.85,,OUTPAT REV HCPCS COMBO 1, 47.49,OTHER, 9.37, 90.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28492,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.68,,OUTPAT REV HCPCS COMBO 1, 41.70,OTHER, 19.28, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28493,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 49.11,,OUTPAT REV HCPCS COMBO 1, 59.73,OTHER, 16.63, 111.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28494,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 26.30,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28495,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 26.30,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28496,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 26.30,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28497,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.88,,OUTPAT REV HCPCS COMBO 1, 39.11,OTHER, 7.46, 74.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28498,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.88,,OUTPAT REV HCPCS COMBO 1, 39.11,OTHER, 7.46, 74.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28499,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 79.45,,OUTPAT REV HCPCS COMBO 1, 93.47,OTHER, 13.62, 181.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28500,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 79.45,,OUTPAT REV HCPCS COMBO 1, 93.47,OTHER, 13.62, 181.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28501,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.12,,OUTPAT REV HCPCS COMBO 1, 45.06,OTHER, 16.97, 82.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28502,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.16,,OUTPAT REV HCPCS COMBO 1, 76.21,OTHER, 9.31, 148.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28503,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 59.05,,OUTPAT REV HCPCS COMBO 1, 72.23,OTHER, 21.72, 134.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28504,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 59.05,,OUTPAT REV HCPCS COMBO 1, 72.23,OTHER, 21.72, 134.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28505,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 60.77,,OUTPAT REV HCPCS COMBO 1, 75.36,OTHER, 26.66, 138.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28506,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 60.77,,OUTPAT REV HCPCS COMBO 1, 75.36,OTHER, 26.66, 138.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28507,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 104.58,,OUTPAT REV HCPCS COMBO 1, 127.42,OTHER, 36.38, 238.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28508,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 104.58,,OUTPAT REV HCPCS COMBO 1, 127.42,OTHER, 36.38, 238.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28509,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 76.99,,OUTPAT REV HCPCS COMBO 1, 93.87,OTHER, 27.06, 175.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28510,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 110.87,,OUTPAT REV HCPCS COMBO 1, 135.49,OTHER, 40.24, 252.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28511,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 110.87,,OUTPAT REV HCPCS COMBO 1, 135.49,OTHER, 40.24, 252.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28512,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 64.07,,OUTPAT REV HCPCS COMBO 1, 83.83,OTHER, 46.51, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28513,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 57.62,,OUTPAT REV HCPCS COMBO 1, 73.72,OTHER, 34.82, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28514,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 58.91,,OUTPAT REV HCPCS COMBO 1, 75.45,OTHER, 35.93, 134.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28515,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 100.08,,OUTPAT REV HCPCS COMBO 1, 121.64,OTHER, 33.53, 228.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28516,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 59.37,,OUTPAT REV HCPCS COMBO 1, 69.17,OTHER, 7.34, 135.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28517,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 104.71,,OUTPAT REV HCPCS COMBO 1, 124.67,OTHER, 24.19, 238.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28518,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 63.21,,OUTPAT REV HCPCS COMBO 1, 76.46,OTHER, 19.63, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28519,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 58.51,,OUTPAT REV HCPCS COMBO 1, 71.48,OTHER, 21.17, 133.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28520,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 182.22,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28521,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 66.65,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28522,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.48,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28523,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.48,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28524,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.48,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28525,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 52.23,,OUTPAT REV HCPCS COMBO 1, 64.96,OTHER, 23.70, 119.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28526,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.38,,OUTPAT REV HCPCS COMBO 1, 34.98,OTHER, 11.54, 64.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28527,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 171.35,,OUTPAT REV HCPCS COMBO 1, 203.52,OTHER, 37.54, 390.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28528,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 49.02,,OUTPAT REV HCPCS COMBO 1, 61.71,OTHER, 25.39, 111.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28529,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 21.39,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28530,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 21.39,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28531,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 21.39,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28532,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 23.75,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28533,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 23.75,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28534,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 23.75,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28535,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 11.27,,OUTPAT REV HCPCS COMBO 1, 14.14,OTHER, 5.66, 25.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28536,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 55.33,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 6.84, 126.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28537,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 55.33,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 6.84, 126.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28538,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 48.07,,OUTPAT REV HCPCS COMBO 1, 57.91,OTHER, 13.97, 109.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28539,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 30.89,,OUTPAT REV HCPCS COMBO 1, 37.55,OTHER, 10.37, 70.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28540,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 77.81,,OUTPAT REV HCPCS COMBO 1, 94.73,OTHER, 26.76, 177.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28541,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 77.81,,OUTPAT REV HCPCS COMBO 1, 94.73,OTHER, 26.76, 177.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28542,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 77.64,,OUTPAT REV HCPCS COMBO 1, 94.52,OTHER, 26.66, 176.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28543,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 77.64,,OUTPAT REV HCPCS COMBO 1, 94.52,OTHER, 26.66, 176.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28544,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 55.24,,OUTPAT REV HCPCS COMBO 1, 67.05,OTHER, 18.12, 125.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28545,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 59.34,,OUTPAT REV HCPCS COMBO 1, 74.92,OTHER, 31.62, 135.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28546,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 39.60,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28547,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 39.60,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28548,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 39.60,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28549,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 82.50,,OUTPAT REV HCPCS COMBO 1, 99.83,OTHER, 25.80, 188.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28550,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 129.43,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28551,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28552,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28553,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28554,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28555,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28556,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 127.54,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28557,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 77.00,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28558,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 118.72,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28559,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 18.49,,OUTPAT REV HCPCS COMBO 1, 25.93,OTHER, 18.49, 42.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28560,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 57.34,,OUTPAT REV HCPCS COMBO 1, 69.04,OTHER, 16.46, 130.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28561,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.69,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28562,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.69,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28563,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.69,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28564,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28565,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28566,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28567,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28568,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 58.18,,OUTPAT REV HCPCS COMBO 1, 70.04,OTHER, 16.66, 132.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28569,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 37.18,,OUTPAT REV HCPCS COMBO 1, 51.00,OTHER, 8.70, 111.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28570,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 48.99,,OUTPAT REV HCPCS COMBO 1, 51.00,OTHER, 8.70, 111.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28571,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 71.38,,OUTPAT REV HCPCS COMBO 1, 85.45,OTHER, 18.42, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28572,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.77,OTHER, 28.37, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28573,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 44.57,,OUTPAT REV HCPCS COMBO 1, 54.77,OTHER, 17.44, 101.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28574,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 44.57,,OUTPAT REV HCPCS COMBO 1, 54.77,OTHER, 17.44, 101.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28575,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 60.48,OTHER, 9.92, 116.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28576,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 51.17,,OUTPAT REV HCPCS COMBO 1, 60.48,OTHER, 9.92, 116.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28577,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 117.27,,OUTPAT REV HCPCS COMBO 1, 149.05,OTHER, 66.68, 267.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28578,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 27.95,,OUTPAT REV HCPCS COMBO 1, 43.46,OTHER, 27.95, 63.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28579,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 34.70,,OUTPAT REV HCPCS COMBO 1, 43.01,OTHER, 15.12, 79.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28580,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 34.70,,OUTPAT REV HCPCS COMBO 1, 43.01,OTHER, 15.12, 79.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28581,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 33.76,,OUTPAT REV HCPCS COMBO 1, 40.64,OTHER, 9.65, 76.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28582,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 172.39,,OUTPAT REV HCPCS COMBO 1, 204.04,OTHER, 34.72, 392.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28583,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.72,,OUTPAT REV HCPCS COMBO 1, 57.49,OTHER, 23.41, 104.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28584,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 135.39,,OUTPAT REV HCPCS COMBO 1, 159.56,OTHER, 24.40, 308.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28585,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 135.39,,OUTPAT REV HCPCS COMBO 1, 159.56,OTHER, 24.40, 308.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28586,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 71.67,,OUTPAT REV HCPCS COMBO 1, 74.79,OTHER, 18.60, 163.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28587,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 52.25,,OUTPAT REV HCPCS COMBO 1, 74.79,OTHER, 18.60, 163.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28588,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 94.17,,OUTPAT REV HCPCS COMBO 1, 120.40,OTHER, 56.53, 214.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28589,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 94.17,,OUTPAT REV HCPCS COMBO 1, 120.40,OTHER, 56.53, 214.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28590,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 91.30,,OUTPAT REV HCPCS COMBO 1, 110.95,OTHER, 30.54, 208.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28591,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.70,,OUTPAT REV HCPCS COMBO 1, 54.17,OTHER, 9.52, 104.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28592,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 37.08,,OUTPAT REV HCPCS COMBO 1, 44.45,OTHER, 9.82, 84.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28593,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 37.08,,OUTPAT REV HCPCS COMBO 1, 44.45,OTHER, 9.82, 84.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28594,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 71.50,,OUTPAT REV HCPCS COMBO 1, 86.15,OTHER, 20.81, 162.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28595,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 116.98,,OUTPAT REV HCPCS COMBO 1, 147.00,OTHER, 59.45, 266.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28596,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 116.98,,OUTPAT REV HCPCS COMBO 1, 147.00,OTHER, 59.45, 266.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28597,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.68,,OUTPAT REV HCPCS COMBO 1, 43.75,OTHER, 27.89, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28598,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 158.40,,OUTPAT REV HCPCS COMBO 1, 186.61,OTHER, 28.27, 361.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28599,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.98,,OUTPAT REV HCPCS COMBO 1, 45.87,OTHER, 7.46, 92.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28600,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 40.68,,OUTPAT REV HCPCS COMBO 1, 45.87,OTHER, 7.46, 92.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28601,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 29.56,,OUTPAT REV HCPCS COMBO 1, 35.19,OTHER, 6.83, 67.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28602,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 29.56,,OUTPAT REV HCPCS COMBO 1, 35.19,OTHER, 6.83, 67.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28603,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 23.99,,OUTPAT REV HCPCS COMBO 1, 28.87,OTHER, 6.85, 54.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28604,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 13.83,OTHER, 6.82, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28605,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 35.72,,OUTPAT REV HCPCS COMBO 1, 45.56,OTHER, 21.01, 81.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28606,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 75.35,,OUTPAT REV HCPCS COMBO 1, 92.72,OTHER, 30.04, 171.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28607,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 75.35,,OUTPAT REV HCPCS COMBO 1, 92.72,OTHER, 30.04, 171.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28608,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 82.30,,OUTPAT REV HCPCS COMBO 1, 102.79,OTHER, 39.19, 187.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28609,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 79.71,,OUTPAT REV HCPCS COMBO 1, 97.17,OTHER, 27.91, 181.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28610,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 71.08,,OUTPAT REV HCPCS COMBO 1, 90.21,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28611,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 76.69,,OUTPAT REV HCPCS COMBO 1, 90.21,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28612,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 76.69,,OUTPAT REV HCPCS COMBO 1, 93.39,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28613,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 20.61,,OUTPAT REV HCPCS COMBO 1, 24.66,OTHER, 5.28, 46.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28614,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 20.61,,OUTPAT REV HCPCS COMBO 1, 24.66,OTHER, 5.28, 46.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28615,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28616,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28617,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28618,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 35.17,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28619,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 35.17,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28620,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.73,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28621,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 171.18,,OUTPAT REV HCPCS COMBO 1, 144.06,OTHER, 15.47, 390.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28622,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 76.05,,OUTPAT REV HCPCS COMBO 1, 144.06,OTHER, 15.47, 390.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28623,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.58,,OUTPAT REV HCPCS COMBO 1, 141.59,OTHER, 25.68, 394.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28624,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 173.02,,OUTPAT REV HCPCS COMBO 1, 141.59,OTHER, 25.68, 394.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28625,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 112.01,,OUTPAT REV HCPCS COMBO 1, 136.35,OTHER, 38.44, 255.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28626,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 82.46,,OUTPAT REV HCPCS COMBO 1, 103.27,OTHER, 40.46, 187.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28627,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 61.06,,OUTPAT REV HCPCS COMBO 1, 76.88,OTHER, 31.67, 139.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28628,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 151.36,,OUTPAT REV HCPCS COMBO 1, 178.83,OTHER, 29.15, 344.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28629,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 71.31,,OUTPAT REV HCPCS COMBO 1, 88.43,OTHER, 31.30, 162.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28630,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 24.98,,OUTPAT REV HCPCS COMBO 1, 30.02,OTHER, 6.92, 56.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28631,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 24.98,,OUTPAT REV HCPCS COMBO 1, 30.02,OTHER, 6.92, 56.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28632,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 38.86,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28633,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 38.86,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28634,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 7.98,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28635,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 152.72,,OUTPAT REV HCPCS COMBO 1, 180.72,OTHER, 30.61, 348.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28636,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 264.33,,OUTPAT REV HCPCS COMBO 1, 302.95,OTHER, 11.66, 602.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28637,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 64.43,,OUTPAT REV HCPCS COMBO 1, 81.90,OTHER, 36.67, 146.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28638,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28639,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28640,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28641,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28642,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 70.02,,OUTPAT REV HCPCS COMBO 1, 86.80,OTHER, 30.58, 159.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28643,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 70.02,,OUTPAT REV HCPCS COMBO 1, 86.80,OTHER, 30.58, 159.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28644,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 89.69,,OUTPAT REV HCPCS COMBO 1, 107.35,OTHER, 23.12, 204.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28645,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 89.69,,OUTPAT REV HCPCS COMBO 1, 107.35,OTHER, 23.12, 204.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28646,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 44.84,,OUTPAT REV HCPCS COMBO 1, 53.27,OTHER, 9.89, 102.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28647,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 44.84,,OUTPAT REV HCPCS COMBO 1, 53.27,OTHER, 9.89, 102.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28648,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 64.16,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28649,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 64.16,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28650,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 64.16,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28651,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 41.28,,OUTPAT REV HCPCS COMBO 1, 51.95,OTHER, 21.29, 94.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28652,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 59.68,,OUTPAT REV HCPCS COMBO 1, 73.53,OTHER, 24.19, 136.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28653,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 120.40,,OUTPAT REV HCPCS COMBO 1, 154.17,OTHER, 73.24, 274.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28654,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 120.40,,OUTPAT REV HCPCS COMBO 1, 154.17,OTHER, 73.24, 274.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28655,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 39.56,,OUTPAT REV HCPCS COMBO 1, 49.79,OTHER, 20.42, 90.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28656,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.18,,OUTPAT REV HCPCS COMBO 1, 38.32,OTHER, 7.46, 73.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28657,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 30.09,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, 7.63, 68.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28658,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 47.67,,OUTPAT REV HCPCS COMBO 1, 58.51,OTHER, 18.37, 108.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28659,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.73,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 8.27, 74.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28660,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.64,,OUTPAT REV HCPCS COMBO 1, 79.41,OTHER, 20.42, 149.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28661,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.64,,OUTPAT REV HCPCS COMBO 1, 79.41,OTHER, 20.42, 149.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28662,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 64.36,,OUTPAT REV HCPCS COMBO 1, 78.90,OTHER, 24.40, 146.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28663,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 64.36,,OUTPAT REV HCPCS COMBO 1, 78.90,OTHER, 24.40, 146.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28664,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 106.98,,OUTPAT REV HCPCS COMBO 1, 126.89,OTHER, 22.69, 243.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28665,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 69.32,,OUTPAT REV HCPCS COMBO 1, 82.99,OTHER, 17.95, 157.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28666,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 69.32,,OUTPAT REV HCPCS COMBO 1, 82.99,OTHER, 17.95, 157.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28667,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 33.26,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28668,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 33.26,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28669,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 33.26,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28670,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 18.22,,OUTPAT REV HCPCS COMBO 1, 22.60,OTHER, 8.00, 41.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28671,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 18.22,,OUTPAT REV HCPCS COMBO 1, 22.60,OTHER, 8.00, 41.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28672,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 26.70,,OUTPAT REV HCPCS COMBO 1, 31.87,OTHER, 6.50, 60.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28673,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.90,,OUTPAT REV HCPCS COMBO 1, 39.10,OTHER, 7.32, 74.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28674,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 63.71,,OUTPAT REV HCPCS COMBO 1, 76.33,OTHER, 16.72, 145.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28675,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 87.18,,OUTPAT REV HCPCS COMBO 1, 103.71,OTHER, 19.75, 198.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28676,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28677,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28678,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28679,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 69.10,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 29.96, 157.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28680,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 80.90,,OUTPAT REV HCPCS COMBO 1, 97.04,OTHER, 21.67, 184.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28681,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.30,,OUTPAT REV HCPCS COMBO 1, 42.88,OTHER, 6.94, 82.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28682,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 37.42,,OUTPAT REV HCPCS COMBO 1, 43.80,OTHER, 5.47, 85.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28683,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 15.00,,OUTPAT REV HCPCS COMBO 1, 17.85,OTHER, 3.41, 34.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28684,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 15.00,,OUTPAT REV HCPCS COMBO 1, 17.85,OTHER, 3.41, 34.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28685,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 18.18,,OUTPAT REV HCPCS COMBO 1, 21.46,OTHER, 3.41, 41.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28686,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 18.18,,OUTPAT REV HCPCS COMBO 1, 21.46,OTHER, 3.41, 41.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28687,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 22.31,OTHER, .01, 84.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28688,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.94,,OUTPAT REV HCPCS COMBO 1, 22.31,OTHER, .01, 84.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28689,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 37.42,,OUTPAT REV HCPCS COMBO 1, 44.71,OTHER, 9.31, 85.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28690,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 31.95,,OUTPAT REV HCPCS COMBO 1, 37.65,OTHER, 5.75, 72.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28691,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 31.95,,OUTPAT REV HCPCS COMBO 1, 37.65,OTHER, 5.75, 72.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28692,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 16.77,,OUTPAT REV HCPCS COMBO 1, 19.92,OTHER, 3.66, 38.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28693,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 27.38,,OUTPAT REV HCPCS COMBO 1, 32.63,OTHER, 6.46, 62.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28694,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 79.81,,OUTPAT REV HCPCS COMBO 1, 96.77,OTHER, 25.78, 181.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28695,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 106.94,,OUTPAT REV HCPCS COMBO 1, 129.31,OTHER, 33.04, 243.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28696,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 111.37,,OUTPAT REV HCPCS COMBO 1, 130.54,OTHER, 17.06, 253.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28697,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 82.42,,OUTPAT REV HCPCS COMBO 1, 98.34,OTHER, 19.93, 187.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28698,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 73.75,,OUTPAT REV HCPCS COMBO 1, 89.00,OTHER, 22.06, 168.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28699,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 83.42,,OUTPAT REV HCPCS COMBO 1, 98.22,OTHER, 14.66, 190.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28700,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.18,,OUTPAT REV HCPCS COMBO 1, 54.63,OTHER, 13.99, 102.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28701,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 56.33,,OUTPAT REV HCPCS COMBO 1, 70.40,OTHER, 27.00, 128.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28702,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 25.05,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28703,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 24.89,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28704,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 25.05,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28705,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28706,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28707,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28708,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28709,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 35.35,,OUTPAT REV HCPCS COMBO 1, 41.60,OTHER, 6.14, 80.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28710,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 22.36,,OUTPAT REV HCPCS COMBO 1, 26.32,OTHER, 3.89, 50.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28711,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 30.35,,OUTPAT REV HCPCS COMBO 1, 36.35,OTHER, 7.93, 69.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28712,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 73.10,,OUTPAT REV HCPCS COMBO 1, 61.85,OTHER, 8.65, 166.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28713,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.20,,OUTPAT REV HCPCS COMBO 1, 61.85,OTHER, 8.65, 166.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28714,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.15,,OUTPAT REV HCPCS COMBO 1, 76.67,OTHER, 11.26, 148.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28715,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 510.99,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28716,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 138.89,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28717,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28718,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28719,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28720,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28721,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28722,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28723,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28724,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28725,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28726,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28727,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28728,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28729,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28730,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28731,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28732,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28733,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28734,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28735,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28736,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28737,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28738,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28739,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28740,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28741,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28742,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28743,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28744,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28745,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28746,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28747,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28748,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28749,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28750,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28751,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28752,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28753,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 26.51,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28754,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28755,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28756,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28757,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28758,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 13.80,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28759,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28760,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28761,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28762,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28763,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28764,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28765,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28766,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28767,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28768,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28769,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28770,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28771,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28772,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28773,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28774,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28775,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28776,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28777,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 161.14,,OUTPAT REV HCPCS COMBO 1, 189.29,OTHER, 26.45, 367.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28778,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 98.39,,OUTPAT REV HCPCS COMBO 1, 115.17,OTHER, 14.46, 224.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28779,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 57.32,,OUTPAT REV HCPCS COMBO 1, 91.70,OTHER, 17.41, 220.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28780,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 96.87,,OUTPAT REV HCPCS COMBO 1, 91.70,OTHER, 17.41, 220.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28781,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 39.70,,OUTPAT REV HCPCS COMBO 1, 48.91,OTHER, 16.07, 90.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28782,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 37.63,,OUTPAT REV HCPCS COMBO 1, 45.23,OTHER, 10.51, 85.75,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28783,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 13.48,,OUTPAT REV HCPCS COMBO 1, 17.08,OTHER, 7.46, 30.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28784,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 13.48,,OUTPAT REV HCPCS COMBO 1, 17.08,OTHER, 7.46, 30.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28785,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 48.27,,OUTPAT REV HCPCS COMBO 1, 59.25,OTHER, 18.65, 110.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28786,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 75.07,,OUTPAT REV HCPCS COMBO 1, 93.98,OTHER, 36.65, 171.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28787,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 113.28,,OUTPAT REV HCPCS COMBO 1, 137.37,OTHER, 36.65, 258.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28788,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 64.24,,OUTPAT REV HCPCS COMBO 1, 78.46,OTHER, 23.14, 146.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28789,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 56.01,,OUTPAT REV HCPCS COMBO 1, 67.64,OTHER, 17.28, 127.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28790,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 55.87,,OUTPAT REV HCPCS COMBO 1, 67.64,OTHER, 17.28, 127.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28791,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 62.28,,OUTPAT REV HCPCS COMBO 1, 77.69,OTHER, 29.26, 141.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28792,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 51.73,,OUTPAT REV HCPCS COMBO 1, 63.19,OTHER, 18.65, 117.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28793,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 51.66,,OUTPAT REV HCPCS COMBO 1, 65.88,OTHER, 19.79, 127.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28794,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 56.08,,OUTPAT REV HCPCS COMBO 1, 65.88,OTHER, 19.79, 127.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28795,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28796,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28797,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28798,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28799,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 60.90,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28800,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28801,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 51.97,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28802,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 48.44,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28803,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 68.37,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28804,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 104.56,,OUTPAT REV HCPCS COMBO 1, 120.82,OTHER, 17.35, 238.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28805,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 100.94,,OUTPAT REV HCPCS COMBO 1, 120.82,OTHER, 17.35, 238.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28806,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 15.65,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28807,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 64.09,,OUTPAT REV HCPCS COMBO 1, 80.94,OTHER, 29.96, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28808,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.89,,OUTPAT REV HCPCS COMBO 1, 80.94,OTHER, 29.96, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28809,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 68.68,,OUTPAT REV HCPCS COMBO 1, 85.12,OTHER, 29.96, 156.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28810,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 84.81,,OUTPAT REV HCPCS COMBO 1, 103.45,OTHER, 29.96, 193.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28811,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 58.18,,OUTPAT REV HCPCS COMBO 1, 125.05,OTHER, 24.97, 345.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28812,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 151.58,,OUTPAT REV HCPCS COMBO 1, 125.05,OTHER, 24.97, 345.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28813,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 42.94,,OUTPAT REV HCPCS COMBO 1, 50.54,OTHER, 7.46, 97.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28814,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 71.51,,OUTPAT REV HCPCS COMBO 1, 88.87,OTHER, 32.17, 162.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28815,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 52.03,,OUTPAT REV HCPCS COMBO 1, 66.43,OTHER, 30.83, 118.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28816,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 46.01,,OUTPAT REV HCPCS COMBO 1, 57.43,OTHER, 21.72, 104.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28817,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 226.29,,OUTPAT REV HCPCS COMBO 1, 265.06,OTHER, 33.95, 515.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28818,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 63.21,,OUTPAT REV HCPCS COMBO 1, 80.97,OTHER, 38.57, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28819,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 63.21,,OUTPAT REV HCPCS COMBO 1, 80.97,OTHER, 38.57, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28820,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 87.08,,OUTPAT REV HCPCS COMBO 1, 111.82,OTHER, 54.34, 198.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28821,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 141.00,,OUTPAT REV HCPCS COMBO 1, 176.22,OTHER, 67.64, 321.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28822,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 69.45,,OUTPAT REV HCPCS COMBO 1, 88.05,OTHER, 38.57, 158.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28823,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 69.45,,OUTPAT REV HCPCS COMBO 1, 88.05,OTHER, 38.57, 158.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28824,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 57.62,,OUTPAT REV HCPCS COMBO 1, 68.73,OTHER, 13.84, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28825,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 70.14,,OUTPAT REV HCPCS COMBO 1, 96.09,OTHER, 20.95, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28826,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 90.30,,OUTPAT REV HCPCS COMBO 1, 96.09,OTHER, 20.95, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28827,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 57.62,,OUTPAT REV HCPCS COMBO 1, 70.10,OTHER, 19.60, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28828,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 39.55,,OUTPAT REV HCPCS COMBO 1, 46.86,OTHER, 8.16, 90.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28829,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 39.55,,OUTPAT REV HCPCS COMBO 1, 46.86,OTHER, 8.16, 90.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28830,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 150.07,,OUTPAT REV HCPCS COMBO 1, 191.67,OTHER, 89.24, 342.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28831,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 8.04,,OUTPAT REV HCPCS COMBO 1, 12.31,OTHER, 8.04, 18.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28832,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 15.01,,OUTPAT REV HCPCS COMBO 1, 18.56,OTHER, 6.34, 34.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28833,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 27.34,,OUTPAT REV HCPCS COMBO 1, 36.21,OTHER, 21.67, 62.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28834,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.58,,OUTPAT REV HCPCS COMBO 1, 55.25,OTHER, 14.66, 103.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28835,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 31.44,,OUTPAT REV HCPCS COMBO 1, 40.13,OTHER, 18.58, 71.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28836,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 66.54,OTHER, 19.00, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28837,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 72.68,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28838,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 72.68,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28839,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 72.68,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28840,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 19.93,,OUTPAT REV HCPCS COMBO 1, 26.75,OTHER, 17.29, 45.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28841,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 41.68,,OUTPAT REV HCPCS COMBO 1, 91.08,OTHER, 16.51, 254.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28842,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 111.80,,OUTPAT REV HCPCS COMBO 1, 91.08,OTHER, 16.51, 254.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28843,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 40.42,,OUTPAT REV HCPCS COMBO 1, 50.83,OTHER, 20.72, 92.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28844,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 46.87,,OUTPAT REV HCPCS COMBO 1, 59.00,OTHER, 24.26, 106.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28845,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 52.14,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 22.02, 118.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28846,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 46.92,,OUTPAT REV HCPCS COMBO 1, 59.50,OTHER, 26.12, 106.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28847,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 46.92,,OUTPAT REV HCPCS COMBO 1, 59.50,OTHER, 26.12, 106.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28848,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 78.68,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28849,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 47.36,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28850,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 47.36,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28851,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 52.89,,OUTPAT REV HCPCS COMBO 1, 66.70,OTHER, 27.86, 120.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28852,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 52.89,,OUTPAT REV HCPCS COMBO 1, 66.70,OTHER, 27.86, 120.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28853,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 33.97,,OUTPAT REV HCPCS COMBO 1, 43.51,OTHER, 20.72, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28854,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 38.00,,OUTPAT REV HCPCS COMBO 1, 47.68,OTHER, 19.00, 86.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28855,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.58,,OUTPAT REV HCPCS COMBO 1, 58.39,OTHER, 27.86, 103.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28856,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 64.05,,OUTPAT REV HCPCS COMBO 1, 77.47,OTHER, 19.86, 145.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28857,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 50.90,,OUTPAT REV HCPCS COMBO 1, 62.50,OTHER, 19.74, 116.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28858,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 37.53,,OUTPAT REV HCPCS COMBO 1, 46.75,OTHER, 17.35, 85.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28859,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.68,,OUTPAT REV HCPCS COMBO 1, 41.14,OTHER, 16.94, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28860,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 55.83,,OUTPAT REV HCPCS COMBO 1, 67.08,OTHER, 15.47, 127.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28861,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 40.75,,OUTPAT REV HCPCS COMBO 1, 50.52,OTHER, 17.84, 92.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28862,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 21.41,,OUTPAT REV HCPCS COMBO 1, 28.18,OTHER, 16.21, 48.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28863,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 42.33,,OUTPAT REV HCPCS COMBO 1, 52.54,OTHER, 18.79, 96.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28864,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 42.33,,OUTPAT REV HCPCS COMBO 1, 52.54,OTHER, 18.79, 96.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28865,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 41.16,OTHER, 19.07, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28866,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.26,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28867,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.26,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28868,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.26,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28869,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 37.52,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28870,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 38.81,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28871,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 38.81,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28872,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 39.49,,OUTPAT REV HCPCS COMBO 1, 49.38,OTHER, 19.07, 89.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28873,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 66.65,,OUTPAT REV HCPCS COMBO 1, 80.11,OTHER, 18.55, 151.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28874,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 66.65,,OUTPAT REV HCPCS COMBO 1, 80.11,OTHER, 18.55, 151.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28875,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 314.67,,OUTPAT REV HCPCS COMBO 1, 361.76,OTHER, 18.55, 717.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28876,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 138.03,,OUTPAT REV HCPCS COMBO 1, 161.64,OTHER, 20.54, 314.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28877,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 120.30,,OUTPAT REV HCPCS COMBO 1, 158.63,OTHER, 92.44, 274.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28878,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 120.30,,OUTPAT REV HCPCS COMBO 1, 158.63,OTHER, 92.44, 274.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28879,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.75,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28880,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.75,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28881,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.75,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28882,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 102.77,,OUTPAT REV HCPCS COMBO 1, 152.44,OTHER, 102.77, 234.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28883,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28884,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28885,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28886,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28887,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28888,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28889,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28890,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28891,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 127.76,,OUTPAT REV HCPCS COMBO 1, 146.86,OTHER, 7.46, 291.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28892,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 47.30,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28893,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 47.30,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28894,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 47.30,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28895,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 39.16,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28896,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 37.22,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28897,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 39.16,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28898,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28899,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 185.27,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28900,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 168.35,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28901,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 59.99,,OUTPAT REV HCPCS COMBO 1, 70.78,OTHER, 11.16, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28902,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 59.99,,OUTPAT REV HCPCS COMBO 1, 70.78,OTHER, 11.16, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28903,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28904,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28905,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28906,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28907,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28908,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28909,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 59.99,,OUTPAT REV HCPCS COMBO 1, 76.50,OTHER, 35.20, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28910,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 112.23,,OUTPAT REV HCPCS COMBO 1, 149.18,OTHER, 91.25, 255.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28911,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 68.57,,OUTPAT REV HCPCS COMBO 1, 81.41,OTHER, 14.86, 156.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28912,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 68.57,,OUTPAT REV HCPCS COMBO 1, 81.41,OTHER, 14.86, 156.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28913,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 24.24,,OUTPAT REV HCPCS COMBO 1, 30.76,OTHER, 13.60, 55.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28914,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 61.36,,OUTPAT REV HCPCS COMBO 1, 72.64,OTHER, 12.41, 139.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28915,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 61.36,,OUTPAT REV HCPCS COMBO 1, 72.64,OTHER, 12.41, 139.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28916,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 66.06,,OUTPAT REV HCPCS COMBO 1, 78.26,OTHER, 13.63, 150.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28917,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 66.06,,OUTPAT REV HCPCS COMBO 1, 78.26,OTHER, 13.63, 150.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28918,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 67.12,,OUTPAT REV HCPCS COMBO 1, 78.99,OTHER, 11.64, 152.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28919,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 38.75,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28920,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 38.75,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28921,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 38.75,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28922,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 34.07,,OUTPAT REV HCPCS COMBO 1, 40.96,OTHER, 9.55, 77.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28923,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.91,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28924,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.91,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28925,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.91,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28926,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 70.00,,OUTPAT REV HCPCS COMBO 1, 82.26,OTHER, 11.65, 159.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28927,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 70.00,,OUTPAT REV HCPCS COMBO 1, 82.26,OTHER, 11.65, 159.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28928,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 63.28,,OUTPAT REV HCPCS COMBO 1, 74.74,OTHER, 12.11, 144.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28929,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 76.88,,OUTPAT REV HCPCS COMBO 1, 91.00,OTHER, 15.55, 175.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28930,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 57.47,,OUTPAT REV HCPCS COMBO 1, 68.31,OTHER, 12.82, 130.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28931,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 14.19,,OUTPAT REV HCPCS COMBO 1, 17.74,OTHER, 6.84, 32.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28932,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 17.99,,OUTPAT REV HCPCS COMBO 1, 22.99,OTHER, 10.78, 40.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28933,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 24.94,,OUTPAT REV HCPCS COMBO 1, 29.95,OTHER, 6.84, 56.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28934,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 34.74,,OUTPAT REV HCPCS COMBO 1, 42.41,OTHER, 12.46, 79.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28935,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 24.33,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28936,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 22.66,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28937,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 22.66,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28938,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 22.74,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28939,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 22.74,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28940,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 31.96,,OUTPAT REV HCPCS COMBO 1, 38.14,OTHER, 7.76, 72.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28941,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 31.96,,OUTPAT REV HCPCS COMBO 1, 38.14,OTHER, 7.76, 72.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28942,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 23.16,,OUTPAT REV HCPCS COMBO 1, 28.29,OTHER, 8.38, 52.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28943,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.72,OTHER, 28.16, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28944,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 260.02,,OUTPAT REV HCPCS COMBO 1, 299.39,OTHER, 17.26, 592.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28945,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.69,,OUTPAT REV HCPCS COMBO 1, 40.67,OTHER, 14.88, 74.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28946,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 34.45,,OUTPAT REV HCPCS COMBO 1, 43.08,OTHER, 16.61, 78.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28947,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 102.77,,OUTPAT REV HCPCS COMBO 1, 121.25,OTHER, 19.08, 234.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28948,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.89,OTHER, 28.87, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28949,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28950,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28951,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28952,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28953,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28954,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 162.17,,OUTPAT REV HCPCS COMBO 1, 198.86,OTHER, 61.69, 369.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28955,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 162.17,,OUTPAT REV HCPCS COMBO 1, 198.86,OTHER, 61.69, 369.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28956,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 67.57,,OUTPAT REV HCPCS COMBO 1, 100.71,OTHER, 67.57, 153.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28957,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 182.09,,OUTPAT REV HCPCS COMBO 1, 221.47,OTHER, 61.69, 415.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28958,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 56.71,,OUTPAT REV HCPCS COMBO 1, 76.43,OTHER, 50.53, 129.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28959,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 207.69,,OUTPAT REV HCPCS COMBO 1, 265.03,OTHER, 122.54, 473.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28960,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 82.99,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28961,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 64.50,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28962,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 64.50,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28963,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 266.63,,OUTPAT REV HCPCS COMBO 1, 445.68,OTHER, 266.63, 607.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28964,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28965,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28966,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28967,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 160.23,,OUTPAT REV HCPCS COMBO 1, 193.99,OTHER, 50.53, 365.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28968,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 160.23,,OUTPAT REV HCPCS COMBO 1, 193.99,OTHER, 50.53, 365.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28969,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28970,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 142.33,,OUTPAT REV HCPCS COMBO 1, 173.66,OTHER, 50.53, 324.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28971,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.89,OTHER, 28.87, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28972,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 75.34,,OUTPAT REV HCPCS COMBO 1, 204.22,OTHER, 50.53, 599.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28973,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 263.13,,OUTPAT REV HCPCS COMBO 1, 204.22,OTHER, 50.53, 599.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28974,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 116.09,,OUTPAT REV HCPCS COMBO 1, 146.52,OTHER, 61.69, 264.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28975,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 116.09,,OUTPAT REV HCPCS COMBO 1, 146.52,OTHER, 61.69, 264.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28976,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 62.25,OTHER, 23.83, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28977,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 49.82,,OUTPAT REV HCPCS COMBO 1, 62.25,OTHER, 23.83, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28978,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 33.97,,OUTPAT REV HCPCS COMBO 1, 43.07,OTHER, 18.86, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28979,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 33.97,,OUTPAT REV HCPCS COMBO 1, 43.07,OTHER, 18.86, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28980,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 33.97,,OUTPAT REV HCPCS COMBO 1, 44.25,OTHER, 23.81, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28981,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 10.75,,OUTPAT REV HCPCS COMBO 1, 17.88,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28982,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 83.33,,OUTPAT REV HCPCS COMBO 1, 100.14,OTHER, 23.14, 189.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28983,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 627.37,,OUTPAT REV HCPCS COMBO 1, 800.72,OTHER, 370.73, 1429.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28984,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 627.37,,OUTPAT REV HCPCS COMBO 1, 800.72,OTHER, 370.73, 1429.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28985,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 59.91,OTHER, 38.32, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28986,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 59.91,OTHER, 38.32, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28987,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 238.65,,OUTPAT REV HCPCS COMBO 1, 294.34,OTHER, 97.97, 543.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28988,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28989,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28990,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 13.33,,OUTPAT REV HCPCS COMBO 1, 16.75,OTHER, 6.79, 30.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28991,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 13.33,,OUTPAT REV HCPCS COMBO 1, 16.75,OTHER, 6.79, 30.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28992,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 48.34,,OUTPAT REV HCPCS COMBO 1, 56.81,OTHER, 8.06, 110.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28993,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.99,,OUTPAT REV HCPCS COMBO 1, 39.98,OTHER, 10.56, 75.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28994,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 33.11,,OUTPAT REV HCPCS COMBO 1, 41.73,OTHER, 17.35, 75.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28995,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2550.94,,OUTPAT REV HCPCS COMBO 1, 3802.17,OTHER, 2550.94, 5813.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28996,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 48.44,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28997,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 48.44,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28998,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 12.69,,OUTPAT REV HCPCS COMBO 1, 23.30,OTHER, 12.69, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 28999,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 25.59,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29000,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 12.79,,OUTPAT REV HCPCS COMBO 1, 23.42,OTHER, 12.79, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29001,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 55.47,,OUTPAT REV HCPCS COMBO 1, 82.68,OTHER, 55.47, 126.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29002,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29003,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.79,,OUTPAT REV HCPCS COMBO 1, 149.84,OTHER, 65.79, 315.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29004,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.79,,OUTPAT REV HCPCS COMBO 1, 149.84,OTHER, 65.79, 315.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29005,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 59.75,,OUTPAT REV HCPCS COMBO 1, 89.06,OTHER, 59.75, 136.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29006,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 21.50,,OUTPAT REV HCPCS COMBO 1, 41.40,OTHER, 21.50, 71.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29007,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 21.50,,OUTPAT REV HCPCS COMBO 1, 41.40,OTHER, 21.50, 71.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29008,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 255.16,,OUTPAT REV HCPCS COMBO 1, 356.50,OTHER, 255.16, 581.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29009,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 533.11,,OUTPAT REV HCPCS COMBO 1, 687.64,OTHER, 345.38, 1214.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29010,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 135.24,,OUTPAT REV HCPCS COMBO 1, 201.57,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29011,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29012,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29013,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.55,,OUTPAT REV HCPCS COMBO 1, 60.00,OTHER, 36.55, 83.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29014,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 22.12,,OUTPAT REV HCPCS COMBO 1, 36.74,OTHER, 22.12, 50.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29015,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 22.12,,OUTPAT REV HCPCS COMBO 1, 36.74,OTHER, 22.12, 50.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29016,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29017,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29018,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29019,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29020,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29021,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29022,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29023,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 34.29,,OUTPAT REV HCPCS COMBO 1, 51.11,OTHER, 34.29, 78.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29024,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 58.79,,OUTPAT REV HCPCS COMBO 1, 87.62,OTHER, 58.79, 133.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29025,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 58.79,,OUTPAT REV HCPCS COMBO 1, 87.62,OTHER, 58.79, 133.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29026,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29027,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 67.85,,OUTPAT REV HCPCS COMBO 1, 111.30,OTHER, 67.85, 154.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29028,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 67.85,,OUTPAT REV HCPCS COMBO 1, 111.30,OTHER, 67.85, 154.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29029,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29030,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29031,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 73.49,,OUTPAT REV HCPCS COMBO 1, 104.75,OTHER, 73.49, 167.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29032,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 73.49,,OUTPAT REV HCPCS COMBO 1, 104.75,OTHER, 73.49, 167.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29033,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 4.30,,OUTPAT REV HCPCS COMBO 1, 12.78,OTHER, 4.30, 33.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29034,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 14.22,,OUTPAT REV HCPCS COMBO 1, 17.36,OTHER, 5.09, 32.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29035,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 130.68,,OUTPAT REV HCPCS COMBO 1, 184.48,OTHER, 130.68, 297.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29036,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 146.42,,OUTPAT REV HCPCS COMBO 1, 202.35,OTHER, 146.42, 333.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29037,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 63.61,,OUTPAT REV HCPCS COMBO 1, 99.37,OTHER, 63.61, 144.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29038,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.39,,OUTPAT REV HCPCS COMBO 1, 88.44,OTHER, 59.56, 149.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29039,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 84.22,,OUTPAT REV HCPCS COMBO 1, 131.72,OTHER, 84.22, 191.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29040,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 82.81,,OUTPAT REV HCPCS COMBO 1, 117.05,OTHER, 82.81, 188.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29041,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 126.51,,OUTPAT REV HCPCS COMBO 1, 179.75,OTHER, 126.51, 288.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29042,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 109.46,,OUTPAT REV HCPCS COMBO 1, 158.52,OTHER, 109.46, 249.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29043,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 132.20,,OUTPAT REV HCPCS COMBO 1, 186.21,OTHER, 132.20, 301.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29044,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 63.26,,OUTPAT REV HCPCS COMBO 1, 83.96,OTHER, 50.93, 144.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29045,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 102.00,,OUTPAT REV HCPCS COMBO 1, 167.44,OTHER, 102.00, 232.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29046,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 106.26,,OUTPAT REV HCPCS COMBO 1, 172.28,OTHER, 106.26, 242.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29047,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 25.59,,OUTPAT REV HCPCS COMBO 1, 49.86,OTHER, 25.59, 87.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29048,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 106.61,,OUTPAT REV HCPCS COMBO 1, 141.43,OTHER, 85.51, 242.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29049,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.42,,OUTPAT REV HCPCS COMBO 1, 69.71,OTHER, 45.42, 103.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29050,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 120.47,,OUTPAT REV HCPCS COMBO 1, 177.65,OTHER, 120.47, 274.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29051,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 130.87,,OUTPAT REV HCPCS COMBO 1, 189.46,OTHER, 130.87, 298.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29052,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 210.54,,OUTPAT REV HCPCS COMBO 1, 279.93,OTHER, 171.54, 479.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29053,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 197.39,,OUTPAT REV HCPCS COMBO 1, 265.00,OTHER, 171.54, 449.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29054,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 108.18,,OUTPAT REV HCPCS COMBO 1, 149.90,OTHER, 108.18, 246.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29055,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 137.41,,OUTPAT REV HCPCS COMBO 1, 167.02,OTHER, 46.09, 313.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29056,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 57.35,,OUTPAT REV HCPCS COMBO 1, 76.10,OTHER, 46.09, 130.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29057,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 120.09,,OUTPAT REV HCPCS COMBO 1, 147.35,OTHER, 46.09, 273.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29058,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 174.02,,OUTPAT REV HCPCS COMBO 1, 227.22,OTHER, 124.32, 396.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29059,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 234.14,,OUTPAT REV HCPCS COMBO 1, 295.49,OTHER, 124.32, 533.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29060,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 74.67,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 74.67, 170.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29061,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 110.85,,OUTPAT REV HCPCS COMBO 1, 155.48,OTHER, 110.85, 252.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29062,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 17.18,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29063,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 17.18,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29064,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 17.18,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29065,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 8.41,,OUTPAT REV HCPCS COMBO 1, 36.72,OTHER, 8.41, 114.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29066,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 158.39,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 114.13, 360.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29067,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 158.39,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 114.13, 360.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29068,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 391.14,,OUTPAT REV HCPCS COMBO 1, 526.62,OTHER, 346.21, 891.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29069,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29070,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29071,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 132.44,,OUTPAT REV HCPCS COMBO 1, 162.12,OTHER, 49.24, 301.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29072,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 106.64,,OUTPAT REV HCPCS COMBO 1, 140.39,OTHER, 80.99, 243.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29073,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 106.64,,OUTPAT REV HCPCS COMBO 1, 140.39,OTHER, 80.99, 243.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29074,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 136.31,,OUTPAT REV HCPCS COMBO 1, 166.97,OTHER, 51.13, 310.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29075,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 37.67,,OUTPAT REV HCPCS COMBO 1, 54.96,OTHER, 37.67, 85.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29076,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.39,,OUTPAT REV HCPCS COMBO 1, 86.43,OTHER, 51.13, 149.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29077,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 699.47,,OUTPAT REV HCPCS COMBO 1, 950.56,OTHER, 656.16, 1594.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29078,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29079,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 399.90,,OUTPAT REV HCPCS COMBO 1, 545.72,OTHER, 384.68, 911.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29080,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 399.90,,OUTPAT REV HCPCS COMBO 1, 545.72,OTHER, 384.68, 911.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29081,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29082,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29083,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 473.98,,OUTPAT REV HCPCS COMBO 1, 591.97,OTHER, 225.62, 1080.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29084,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29085,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 200.25,,OUTPAT REV HCPCS COMBO 1, 250.40,OTHER, 96.59, 456.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29086,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 200.25,,OUTPAT REV HCPCS COMBO 1, 250.40,OTHER, 96.59, 456.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29087,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29088,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 449.04,,OUTPAT REV HCPCS COMBO 1, 563.65,OTHER, 225.62, 1023.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29089,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29090,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 70.09,,OUTPAT REV HCPCS COMBO 1, 113.30,OTHER, 70.09, 159.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29091,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 70.09,,OUTPAT REV HCPCS COMBO 1, 113.30,OTHER, 70.09, 159.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29092,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29093,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29094,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 215.00,,OUTPAT REV HCPCS COMBO 1, 297.88,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29095,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29096,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 201.13,,OUTPAT REV HCPCS COMBO 1, 262.11,OTHER, 141.55, 458.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29097,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 201.13,,OUTPAT REV HCPCS COMBO 1, 262.11,OTHER, 141.55, 458.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29098,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29099,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29100,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 545.87,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29101,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 545.87,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29102,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 383.08,OTHER, 225.62, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29103,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 545.87,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29104,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29105,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29106,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29107,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29108,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29109,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29110,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29111,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29112,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29113,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29114,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29115,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29116,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 529.82,,OUTPAT REV HCPCS COMBO 1, 655.39,OTHER, 225.62, 1207.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29117,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29118,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1114.13,,OUTPAT REV HCPCS COMBO 1, 1042.14,OTHER, 284.89, 2539.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29119,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 601.78,,OUTPAT REV HCPCS COMBO 1, 1042.14,OTHER, 284.89, 2539.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29120,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 187.48,,OUTPAT REV HCPCS COMBO 1, 184.77,OTHER, 39.56, 427.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29121,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 39.56,,OUTPAT REV HCPCS COMBO 1, 184.77,OTHER, 39.56, 427.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29122,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 452.95,,OUTPAT REV HCPCS COMBO 1, 547.41,OTHER, 138.71, 1032.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29123,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 154.36,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29124,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 154.36,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29125,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 125.79,,OUTPAT REV HCPCS COMBO 1, 199.86,OTHER, 125.79, 286.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29126,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 125.79,,OUTPAT REV HCPCS COMBO 1, 199.86,OTHER, 125.79, 286.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29127,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 263.32,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29128,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 345.29,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29129,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 379.26,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29130,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 263.32,,OUTPAT REV HCPCS COMBO 1, 332.46,OTHER, 140.42, 600.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29131,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 160.29,,OUTPAT REV HCPCS COMBO 1, 239.03,OTHER, 160.29, 365.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29132,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 160.29,,OUTPAT REV HCPCS COMBO 1, 239.03,OTHER, 160.29, 365.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29133,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 174.98,OTHER, 103.88, 239.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29134,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 136.10,OTHER, 76.16, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29135,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 74.39,,OUTPAT REV HCPCS COMBO 1, 140.33,OTHER, 74.39, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29136,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 182.75,,OUTPAT REV HCPCS COMBO 1, 228.33,OTHER, 87.35, 416.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29137,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 22.94,,OUTPAT REV HCPCS COMBO 1, 34.19,OTHER, 22.94, 52.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29138,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29139,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 140.89,,OUTPAT REV HCPCS COMBO 1, 182.46,OTHER, 94.34, 321.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29140,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 140.89,,OUTPAT REV HCPCS COMBO 1, 182.46,OTHER, 94.34, 321.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29141,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 61.67,,OUTPAT REV HCPCS COMBO 1, 125.89,OTHER, 61.67, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29142,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 61.67,,OUTPAT REV HCPCS COMBO 1, 125.89,OTHER, 61.67, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29143,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 316.56,,OUTPAT REV HCPCS COMBO 1, 415.63,OTHER, 235.80, 721.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29144,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1397.50,,OUTPAT REV HCPCS COMBO 1, 1853.96,OTHER, 1121.15, 3185.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29145,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1397.50,,OUTPAT REV HCPCS COMBO 1, 1853.96,OTHER, 1121.15, 3185.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29146,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1677.00,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29147,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1677.00,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29148,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1677.00,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29149,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 116.62,,OUTPAT REV HCPCS COMBO 1, 152.82,OTHER, 85.61, 265.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29150,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 127.40,,OUTPAT REV HCPCS COMBO 1, 165.98,OTHER, 89.47, 290.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29151,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 206.52,,OUTPAT REV HCPCS COMBO 1, 260.74,OTHER, 110.12, 470.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29152,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 206.52,,OUTPAT REV HCPCS COMBO 1, 260.74,OTHER, 110.12, 470.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29153,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 77.49,,OUTPAT REV HCPCS COMBO 1, 96.89,OTHER, 37.34, 176.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29154,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 77.49,,OUTPAT REV HCPCS COMBO 1, 96.89,OTHER, 37.34, 176.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29155,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 245.81,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29156,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 245.81,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29157,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 245.81,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29158,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 70.82,,OUTPAT REV HCPCS COMBO 1, 89.33,OTHER, 37.34, 161.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29159,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 70.85,,OUTPAT REV HCPCS COMBO 1, 89.33,OTHER, 37.34, 161.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29160,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 84.46,,OUTPAT REV HCPCS COMBO 1, 108.89,OTHER, 54.48, 192.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29161,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 84.46,,OUTPAT REV HCPCS COMBO 1, 108.89,OTHER, 54.48, 192.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29162,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 61.89,,OUTPAT REV HCPCS COMBO 1, 92.25,OTHER, 61.89, 141.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29163,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 61.89,,OUTPAT REV HCPCS COMBO 1, 92.25,OTHER, 61.89, 141.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29164,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 66.17,,OUTPAT REV HCPCS COMBO 1, 84.04,OTHER, 37.34, 150.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29165,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 66.17,,OUTPAT REV HCPCS COMBO 1, 84.04,OTHER, 37.34, 150.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29166,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 25.59,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29167,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 25.59,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29168,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 129.36,,OUTPAT REV HCPCS COMBO 1, 159.88,OTHER, 54.48, 294.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29169,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 129.36,,OUTPAT REV HCPCS COMBO 1, 159.88,OTHER, 54.48, 294.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29170,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 73.50,,OUTPAT REV HCPCS COMBO 1, 96.44,OTHER, 54.48, 167.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29171,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 73.50,,OUTPAT REV HCPCS COMBO 1, 96.44,OTHER, 54.48, 167.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29172,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 74.18,,OUTPAT REV HCPCS COMBO 1, 110.56,OTHER, 74.18, 169.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29173,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 74.18,,OUTPAT REV HCPCS COMBO 1, 110.56,OTHER, 74.18, 169.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29174,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 37.82,,OUTPAT REV HCPCS COMBO 1, 47.95,OTHER, 21.01, 86.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29175,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 37.82,,OUTPAT REV HCPCS COMBO 1, 47.95,OTHER, 21.01, 86.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29176,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 41.51,,OUTPAT REV HCPCS COMBO 1, 55.33,OTHER, 34.39, 94.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29177,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 41.51,,OUTPAT REV HCPCS COMBO 1, 55.33,OTHER, 34.39, 94.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29178,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.49,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29179,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.49,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29180,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.49,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29181,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 180.60,,OUTPAT REV HCPCS COMBO 1, 142.33,OTHER, 28.82, 411.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29182,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 57.99,,OUTPAT REV HCPCS COMBO 1, 142.33,OTHER, 28.82, 411.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29183,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 57.99,,OUTPAT REV HCPCS COMBO 1, 72.71,OTHER, 28.82, 132.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29184,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 52.84,,OUTPAT REV HCPCS COMBO 1, 74.33,OTHER, 52.80, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29185,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 52.80,,OUTPAT REV HCPCS COMBO 1, 74.33,OTHER, 52.80, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29186,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 52.84,,OUTPAT REV HCPCS COMBO 1, 74.35,OTHER, 52.84, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29187,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 56.36,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29188,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 56.36,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29189,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 56.36,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29190,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 40.91,,OUTPAT REV HCPCS COMBO 1, 60.80,OTHER, 40.91, 93.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29191,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 40.91,,OUTPAT REV HCPCS COMBO 1, 60.80,OTHER, 40.91, 93.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29192,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 29.08,,OUTPAT REV HCPCS COMBO 1, 47.68,OTHER, 29.08, 66.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29193,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 76.97,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29194,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 76.97,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29195,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 76.97,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29196,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 92.45,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29197,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 92.45,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29198,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 92.45,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29199,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 52.75,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29200,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 52.75,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29201,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 52.75,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29202,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 18.92,,OUTPAT REV HCPCS COMBO 1, 30.33,OTHER, 18.92, 43.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29203,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 113.97,,OUTPAT REV HCPCS COMBO 1, 178.52,OTHER, 113.97, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29204,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 135.24,,OUTPAT REV HCPCS COMBO 1, 202.67,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29205,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 128.04,,OUTPAT REV HCPCS COMBO 1, 194.50,OTHER, 128.04, 291.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29206,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 63.79,,OUTPAT REV HCPCS COMBO 1, 106.37,OTHER, 63.79, 145.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29207,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 109.36,,OUTPAT REV HCPCS COMBO 1, 173.75,OTHER, 109.36, 249.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29208,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 115.60,,OUTPAT REV HCPCS COMBO 1, 180.83,OTHER, 115.60, 263.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29209,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 136.43,,OUTPAT REV HCPCS COMBO 1, 204.49,OTHER, 136.43, 310.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29210,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.89,,OUTPAT REV HCPCS COMBO 1, 108.91,OTHER, 65.89, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29211,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 51.91,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29212,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 51.91,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29213,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 51.91,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29214,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 31.56,,OUTPAT REV HCPCS COMBO 1, 44.69,OTHER, 31.56, 71.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29215,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 54.89,,OUTPAT REV HCPCS COMBO 1, 78.22,OTHER, 54.89, 125.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29216,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 54.89,,OUTPAT REV HCPCS COMBO 1, 78.22,OTHER, 54.89, 125.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29217,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 38.11,,OUTPAT REV HCPCS COMBO 1, 59.17,OTHER, 38.11, 86.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29218,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 49.88,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29219,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 49.88,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29220,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 49.88,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29221,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29222,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 61.82,,OUTPAT REV HCPCS COMBO 1, 93.12,OTHER, 61.82, 140.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29223,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 52.03,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 52.03, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29224,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 113.97,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 52.03, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29225,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 53.32,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29226,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 53.32,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29227,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 53.32,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29228,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29229,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29230,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 60.63,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29231,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29232,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 60.63,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29233,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29234,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29235,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 129.00,,OUTPAT REV HCPCS COMBO 1, 192.27,OTHER, 129.00, 294.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29236,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29237,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29238,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 103.88,,OUTPAT REV HCPCS COMBO 1, 145.27,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29239,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 63.96,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29240,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 63.96,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29241,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 108.39,,OUTPAT REV HCPCS COMBO 1, 161.56,OTHER, 108.39, 247.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29242,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 108.39,,OUTPAT REV HCPCS COMBO 1, 161.56,OTHER, 108.39, 247.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29243,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29244,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29245,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 211.26,,OUTPAT REV HCPCS COMBO 1, 314.88,OTHER, 211.26, 481.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29246,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 211.26,,OUTPAT REV HCPCS COMBO 1, 314.88,OTHER, 211.26, 481.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29247,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 20.47,,OUTPAT REV HCPCS COMBO 1, 30.51,OTHER, 20.47, 46.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29248,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 44.59,,OUTPAT REV HCPCS COMBO 1, 66.46,OTHER, 44.59, 101.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29249,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 44.59,,OUTPAT REV HCPCS COMBO 1, 66.46,OTHER, 44.59, 101.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29250,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 74.56,,OUTPAT REV HCPCS COMBO 1, 111.13,OTHER, 74.56, 169.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29251,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 74.56,,OUTPAT REV HCPCS COMBO 1, 111.13,OTHER, 74.56, 169.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29252,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 110.02,,OUTPAT REV HCPCS COMBO 1, 163.98,OTHER, 110.02, 250.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29253,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 110.02,,OUTPAT REV HCPCS COMBO 1, 163.98,OTHER, 110.02, 250.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29254,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 147.30,,OUTPAT REV HCPCS COMBO 1, 219.55,OTHER, 147.30, 335.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29255,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 147.30,,OUTPAT REV HCPCS COMBO 1, 219.55,OTHER, 147.30, 335.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29256,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29257,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29258,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29259,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29260,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29261,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 115.64,,OUTPAT REV HCPCS COMBO 1, 149.74,OTHER, 77.35, 263.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29262,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 115.64,,OUTPAT REV HCPCS COMBO 1, 149.74,OTHER, 77.35, 263.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29263,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29264,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29265,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 178.88,,OUTPAT REV HCPCS COMBO 1, 233.57,OTHER, 127.82, 407.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29266,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 178.88,,OUTPAT REV HCPCS COMBO 1, 233.57,OTHER, 127.82, 407.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29267,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29268,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29269,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 282.66,,OUTPAT REV HCPCS COMBO 1, 369.55,OTHER, 203.96, 644.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29270,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 282.66,,OUTPAT REV HCPCS COMBO 1, 369.55,OTHER, 203.96, 644.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29271,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29272,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29273,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 443.36,,OUTPAT REV HCPCS COMBO 1, 580.80,OTHER, 324.71, 1010.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29274,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 443.36,,OUTPAT REV HCPCS COMBO 1, 580.80,OTHER, 324.71, 1010.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29275,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29276,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29277,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 739.51,,OUTPAT REV HCPCS COMBO 1, 954.02,OTHER, 479.76, 1685.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29278,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 739.51,,OUTPAT REV HCPCS COMBO 1, 954.02,OTHER, 479.76, 1685.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29279,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29280,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1182.84,,OUTPAT REV HCPCS COMBO 1, 1514.86,OTHER, 720.78, 2695.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29281,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 433.62,,OUTPAT REV HCPCS COMBO 1, 646.30,OTHER, 433.62, 988.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29282,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 19.23,OTHER, 12.90, 29.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29283,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 72.00,,OUTPAT REV HCPCS COMBO 1, 107.32,OTHER, 72.00, 164.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29284,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 72.00,,OUTPAT REV HCPCS COMBO 1, 107.32,OTHER, 72.00, 164.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29285,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 113.31,,OUTPAT REV HCPCS COMBO 1, 167.97,OTHER, 113.31, 258.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29286,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 118.06,,OUTPAT REV HCPCS COMBO 1, 173.37,OTHER, 118.06, 269.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29287,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 123.17,,OUTPAT REV HCPCS COMBO 1, 179.18,OTHER, 123.17, 280.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29288,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 139.26,,OUTPAT REV HCPCS COMBO 1, 197.44,OTHER, 139.26, 317.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29289,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 135.24,,OUTPAT REV HCPCS COMBO 1, 192.88,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29290,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 156.07,,OUTPAT REV HCPCS COMBO 1, 232.62,OTHER, 156.07, 355.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29291,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29292,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 101.97,,OUTPAT REV HCPCS COMBO 1, 155.10,OTHER, 101.97, 232.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29293,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 108.92,,OUTPAT REV HCPCS COMBO 1, 162.99,OTHER, 108.92, 248.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29294,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 118.79,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29295,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 118.79,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29296,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 118.79,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29297,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 121.35,,OUTPAT REV HCPCS COMBO 1, 177.10,OTHER, 121.35, 276.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29298,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 129.39,,OUTPAT REV HCPCS COMBO 1, 192.85,OTHER, 129.39, 294.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29299,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 139.26,,OUTPAT REV HCPCS COMBO 1, 207.56,OTHER, 139.26, 317.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29300,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 37.28,,OUTPAT REV HCPCS COMBO 1, 55.57,OTHER, 37.28, 84.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29301,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 63.96,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29302,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 30.10,,OUTPAT REV HCPCS COMBO 1, 44.86,OTHER, 30.10, 68.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29303,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 114.40,,OUTPAT REV HCPCS COMBO 1, 170.52,OTHER, 114.40, 260.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29304,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 22.74,,OUTPAT REV HCPCS COMBO 1, 33.14,OTHER, 22.74, 51.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29305,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.14,,OUTPAT REV HCPCS COMBO 1, 39.28,OTHER, 28.14, 64.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29306,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 40.58,,OUTPAT REV HCPCS COMBO 1, 60.49,OTHER, 40.58, 92.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29307,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 9.46,,OUTPAT REV HCPCS COMBO 1, 14.10,OTHER, 9.46, 21.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29308,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 9.46,,OUTPAT REV HCPCS COMBO 1, 54.72,OTHER, 9.46, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29309,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 63.96,,OUTPAT REV HCPCS COMBO 1, 54.72,OTHER, 9.46, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29310,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 109.65,,OUTPAT REV HCPCS COMBO 1, 148.65,OTHER, 101.33, 249.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29311,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 118.25,,OUTPAT REV HCPCS COMBO 1, 166.04,OTHER, 118.25, 269.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29312,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 5.48,,OUTPAT REV HCPCS COMBO 1, 8.17,OTHER, 5.48, 12.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29313,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 5.48,,OUTPAT REV HCPCS COMBO 1, 8.17,OTHER, 5.48, 12.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29314,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 165.55,,OUTPAT REV HCPCS COMBO 1, 350.13,OTHER, 165.55, 680.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29315,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 165.55,,OUTPAT REV HCPCS COMBO 1, 350.13,OTHER, 165.55, 680.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29316,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 261.01,,OUTPAT REV HCPCS COMBO 1, 553.11,OTHER, 261.01, 1078.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29317,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 261.01,,OUTPAT REV HCPCS COMBO 1, 553.11,OTHER, 261.01, 1078.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29318,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 152.65,,OUTPAT REV HCPCS COMBO 1, 308.45,OTHER, 152.65, 567.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29319,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 152.65,,OUTPAT REV HCPCS COMBO 1, 308.45,OTHER, 152.65, 567.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29320,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 220.16,,OUTPAT REV HCPCS COMBO 1, 466.19,OTHER, 220.16, 907.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29321,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 220.16,,OUTPAT REV HCPCS COMBO 1, 466.19,OTHER, 220.16, 907.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29322,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 377.54,,OUTPAT REV HCPCS COMBO 1, 562.72,OTHER, 377.54, 860.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29323,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 377.54,,OUTPAT REV HCPCS COMBO 1, 562.72,OTHER, 377.54, 860.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29324,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 419.25,,OUTPAT REV HCPCS COMBO 1, 624.89,OTHER, 419.25, 955.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29325,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 419.25,,OUTPAT REV HCPCS COMBO 1, 624.89,OTHER, 419.25, 955.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29326,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 58.48,,OUTPAT REV HCPCS COMBO 1, 87.16,OTHER, 58.48, 133.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29327,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 27.52,,OUTPAT REV HCPCS COMBO 1, 41.02,OTHER, 27.52, 62.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29328,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29329,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1288.28,,OUTPAT REV HCPCS COMBO 1, 1648.47,OTHER, 779.04, 2936.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29330,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1288.28,,OUTPAT REV HCPCS COMBO 1, 1648.47,OTHER, 779.04, 2936.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29331,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1402.23,,OUTPAT REV HCPCS COMBO 1, 1777.88,OTHER, 779.04, 3195.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29332,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1402.23,,OUTPAT REV HCPCS COMBO 1, 1777.88,OTHER, 779.04, 3195.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29333,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29334,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29335,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 989.00,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29336,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1097.72,OTHER, 508.57, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29337,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1097.72,OTHER, 508.57, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29338,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1162.11,OTHER, 779.04, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29339,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 860.00,,OUTPAT REV HCPCS COMBO 1, 1162.11,OTHER, 779.04, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29340,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 8.23,,OUTPAT REV HCPCS COMBO 1, 9.74,OTHER, 1.66, 18.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29341,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 48.44,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29342,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 11.82,OTHER, 2.58, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29343,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 38.74,,OUTPAT REV HCPCS COMBO 1, 57.75,OTHER, 38.74, 88.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29344,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 20.10,,OUTPAT REV HCPCS COMBO 1, 29.96,OTHER, 20.10, 45.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29345,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 71.08,,OUTPAT REV HCPCS COMBO 1, 88.75,OTHER, 33.71, 162.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29346,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 44.72,,OUTPAT REV HCPCS COMBO 1, 58.81,OTHER, 33.71, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29347,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 168.13,,OUTPAT REV HCPCS COMBO 1, 250.60,OTHER, 168.13, 383.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29348,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 231.89,OTHER, 165.06, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29349,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 169.59,,OUTPAT REV HCPCS COMBO 1, 231.89,OTHER, 165.06, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29350,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 18.28,,OUTPAT REV HCPCS COMBO 1, 35.44,OTHER, 18.28, 61.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29351,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 26.32,,OUTPAT REV HCPCS COMBO 1, 44.57,OTHER, 26.32, 61.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29352,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 29.24,,OUTPAT REV HCPCS COMBO 1, 43.58,OTHER, 29.24, 66.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29353,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29354,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 111.71,,OUTPAT REV HCPCS COMBO 1, 166.51,OTHER, 111.71, 254.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29355,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 40.32,,OUTPAT REV HCPCS COMBO 1, 60.10,OTHER, 40.32, 91.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29356,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 3.30,,OUTPAT REV HCPCS COMBO 1, 4.92,OTHER, 3.30, 7.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29357,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 3.20,,OUTPAT REV HCPCS COMBO 1, 4.77,OTHER, 3.20, 7.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29358,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 8.74,,OUTPAT REV HCPCS COMBO 1, 13.02,OTHER, 8.74, 19.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29359,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 90.30,,OUTPAT REV HCPCS COMBO 1, 134.59,OTHER, 90.30, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29360,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .91,,OUTPAT REV HCPCS COMBO 1, 1.36,OTHER, .91, 2.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29361,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1.41,,OUTPAT REV HCPCS COMBO 1, 2.10,OTHER, 1.41, 3.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29362,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 17.38,,OUTPAT REV HCPCS COMBO 1, 25.91,OTHER, 17.38, 39.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29363,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 62.40,,OUTPAT REV HCPCS COMBO 1, 93.00,OTHER, 62.40, 142.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29364,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .98,,OUTPAT REV HCPCS COMBO 1, 1.46,OTHER, .98, 2.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29365,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .69,,OUTPAT REV HCPCS COMBO 1, 1.03,OTHER, .69, 1.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29366,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 3.46,,OUTPAT REV HCPCS COMBO 1, 5.15,OTHER, 3.46, 7.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29367,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 7.69,,OUTPAT REV HCPCS COMBO 1, 11.46,OTHER, 7.69, 17.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29368,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2.94,,OUTPAT REV HCPCS COMBO 1, 4.38,OTHER, 2.94, 6.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29369,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1.72,,OUTPAT REV HCPCS COMBO 1, 2.56,OTHER, 1.72, 3.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29370,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 5.02,,OUTPAT REV HCPCS COMBO 1, 7.91,OTHER, 5.02, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29371,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 5.59,,OUTPAT REV HCPCS COMBO 1, 7.91,OTHER, 5.02, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29372,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 29.38,,OUTPAT REV HCPCS COMBO 1, 43.79,OTHER, 29.38, 66.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29373,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 15.45,,OUTPAT REV HCPCS COMBO 1, 23.02,OTHER, 15.45, 35.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29374,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 4.52,,OUTPAT REV HCPCS COMBO 1, 6.74,OTHER, 4.52, 10.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29375,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 3.49,,OUTPAT REV HCPCS COMBO 1, 5.20,OTHER, 3.49, 7.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29376,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 171.57,,OUTPAT REV HCPCS COMBO 1, 575.18,OTHER, 171.57, 1597.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29377,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 171.57,,OUTPAT REV HCPCS COMBO 1, 690.66,OTHER, 171.57, 2082.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29378,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 171.57,,OUTPAT REV HCPCS COMBO 1, 656.15,OTHER, 171.57, 1937.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29379,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 171.57,,OUTPAT REV HCPCS COMBO 1, 607.70,OTHER, 171.57, 1734.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29380,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 214.57,,OUTPAT REV HCPCS COMBO 1, 735.35,OTHER, 214.57, 2065.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29381,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 367.65,,OUTPAT REV HCPCS COMBO 1, 421.89,OTHER, 18.42, 837.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29382,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2.06,,OUTPAT REV HCPCS COMBO 1, 3.08,OTHER, 2.06, 4.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29383,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29384,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29385,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29386,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29387,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29388,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29389,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29390,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29391,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29392,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29393,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29394,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29395,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29396,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29397,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29398,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29399,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29400,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29401,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29402,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29403,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29404,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29405,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29406,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29407,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29408,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29409,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29410,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29411,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29412,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29413,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29414,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29415,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29416,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29417,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29418,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29419,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.69,,OUTPAT REV HCPCS COMBO 1, 62.01,OTHER, 42.53, 104.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29420,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 49.02,,OUTPAT REV HCPCS COMBO 1, 73.06,OTHER, 49.02, 111.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29421,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29422,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 215.00,,OUTPAT REV HCPCS COMBO 1, 320.46,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29423,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 18.06,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29424,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29425,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 15.05,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29426,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29427,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 11.61,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29428,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29429,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29430,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29431,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29432,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29433,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1.94,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29434,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29435,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29436,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29437,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 79.09,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29438,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29439,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 77.40,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29440,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 24.94,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29441,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 24.94,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29442,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 142.83,,OUTPAT REV HCPCS COMBO 1, 212.89,OTHER, 142.83, 325.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29443,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 52.37,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29444,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29445,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 423.39,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29446,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 308.33,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29447,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 3.87,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29448,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29449,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29450,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29451,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29452,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29453,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29454,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29455,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29456,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2.58,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29457,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29458,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 43.86,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29459,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 30.89,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29460,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 30.89,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29461,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 32.25,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29462,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 59.16,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29463,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29464,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29465,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29466,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 6.45,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29467,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 7.74,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29468,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 10.32,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29469,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29470,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 12.26,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29471,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 12.26,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29472,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29473,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29474,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29475,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29476,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29477,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29478,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 19.99,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29479,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 4.30,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29480,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1.35,,OUTPAT REV HCPCS COMBO 1, 2.02,OTHER, 1.35, 3.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29481,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 215.43,,OUTPAT REV HCPCS COMBO 1, 321.10,OTHER, 215.43, 490.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29482,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 245.96,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29483,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29484,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29485,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29486,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29487,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29488,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29489,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29490,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 14.63,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29491,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 65.44,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29492,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 61.34,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29493,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 40.07,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29494,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 36.78,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29495,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 111.92,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29496,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 3270.45,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29497,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 19.44,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29498,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29499,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29500,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29501,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29502,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29503,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29504,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 1032.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29505,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29506,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29507,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29508,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29509,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29510,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29511,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 602.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29512,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 602.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29513,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 602.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29514,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29515,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29516,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29517,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29518,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29519,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 28.87,,OUTPAT REV HCPCS COMBO 1, 43.03,OTHER, 28.87, 65.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29520,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 4.30,,OUTPAT REV HCPCS COMBO 1, 6.41,OTHER, 4.30, 9.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29521,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2494.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29522,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2064.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29523,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2064.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29524,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, 2064.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29525,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29526,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29527,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29528,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29529,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29530,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29531,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29532,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29533,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29534,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29535,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29536,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29537,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29538,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29539,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29540,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29541,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29542,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29543,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29544,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29545,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29546,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29547,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29548,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29549,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29550,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29551,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29552,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_MEDICARE,PRESBYTERIAN MEDICARE ADVANTAGE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 29553,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29554,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29555,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29556,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29557,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29558,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29559,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29560,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29561,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29562,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29563,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29564,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29565,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29566,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29567,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29568,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29569,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29570,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29571,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 271.70,OTHER, 142.76, 477.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29572,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 271.70,OTHER, 142.76, 477.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29573,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 168.89,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29574,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 171.36,OTHER, 103.33, 229.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29575,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 273.87,OTHER, 142.76, 481.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29576,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 276.81,OTHER, 142.76, 430.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29577,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 274.44,,CLAIM ADJUSTMENT 3, 242.16,OTHER, 155.70, 354.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29578,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 850.02,OTHER, 203.58, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29579,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1237.88,,CLAIM ADJUSTMENT 3, 667.92,OTHER, 193.86, 1237.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29580,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 274.44,,CLAIM ADJUSTMENT 3, 177.23,OTHER, 68.01, 274.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29581,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 267.92,,CLAIM ADJUSTMENT 3, 131.69,OTHER, 30.91, 267.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29582,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 116.49,OTHER, 56.08, 143.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29583,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 256.74,,CLAIM ADJUSTMENT 3, 405.48,OTHER, 256.74, 597.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29584,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29585,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 256.74,,CLAIM ADJUSTMENT 3, 216.69,OTHER, 107.31, 256.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29586,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29587,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 456.98,,CLAIM ADJUSTMENT 3, 233.68,OTHER, 60.50, 456.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29588,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 158.67,OTHER, 92.29, 204.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29589,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 112.58,OTHER, 70.21, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29590,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 125.44,OTHER, 81.25, 180.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29591,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 114.17,OTHER, 51.67, 151.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29592,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 122.15,OTHER, 60.94, 143.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29593,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 138.81,OTHER, 86.20, 205.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29594,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 117.21,OTHER, 74.19, 164.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29595,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 258.26,OTHER, 90.53, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29596,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 287.58,OTHER, 115.70, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29597,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 334.39,OTHER, 155.88, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29598,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 1514.68,OTHER, 804.50, 2338.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29599,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 1306.30,OTHER, 595.28, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29600,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 925.64,OTHER, 268.49, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29601,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 389.69,OTHER, 87.88, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29602,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 427.24,OTHER, 120.12, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29603,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 457.59,OTHER, 146.17, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29604,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 732.74,OTHER, 102.89, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29605,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1168.49,OTHER, 299.85, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29606,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 300.44,OTHER, 126.74, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29607,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 495.14,OTHER, 178.41, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29608,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 534.75,OTHER, 212.41, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29609,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 572.81,OTHER, 245.09, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29610,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 541.95,OTHER, 218.59, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29611,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 578.99,OTHER, 250.39, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29612,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 1505.88,OTHER, 766.62, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29613,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 646.89,OTHER, 308.68, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29614,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1242.56,OTHER, 363.44, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29615,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 513.14,OTHER, 193.86, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29616,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 520.86,OTHER, 200.49, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29617,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 694.73,OTHER, 349.75, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29618,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 947.76,OTHER, 287.48, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29619,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1393.28,OTHER, 492.83, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29620,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 56.01,OTHER, 24.73, 76.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29621,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 185.53,OTHER, 86.20, 331.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29622,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 97.29,OTHER, 57.09, 126.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29623,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 97.14,OTHER, 56.97, 126.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29624,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 57.02,OTHER, 22.52, 86.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29625,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 372.97,OTHER, 189.00, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29626,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1446.78,OTHER, 538.75, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29627,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1121.68,OTHER, 259.66, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29628,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 383.22,,CLAIM ADJUSTMENT 3, 278.63,OTHER, 165.01, 383.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29629,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 383.22,,CLAIM ADJUSTMENT 3, 427.61,OTHER, 296.20, 675.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29630,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 237.66,OTHER, 143.26, 408.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29631,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 253.66,OTHER, 143.26, 440.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29632,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 272.17,OTHER, 143.26, 477.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29633,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 251.39,OTHER, 143.26, 436.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29634,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 261.55,OTHER, 143.26, 400.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29635,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 264.56,OTHER, 143.26, 462.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29636,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 306.35,OTHER, 204.98, 467.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29637,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 548.12,OTHER, 309.01, 833.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29638,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 132.82,,CLAIM ADJUSTMENT 3, 300.52,OTHER, 132.82, 482.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29639,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 132.82,,CLAIM ADJUSTMENT 3, 293.08,OTHER, 132.82, 524.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29640,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 1023.77,OTHER, 309.01, 1906.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29641,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 498.22,OTHER, 309.01, 738.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29642,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 435.32,,CLAIM ADJUSTMENT 3, 1703.49,OTHER, 435.32, 3210.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29643,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 435.32,,CLAIM ADJUSTMENT 3, 601.46,OTHER, 382.87, 849.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29644,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2347.12,,CLAIM ADJUSTMENT 3, 2228.68,OTHER, 1193.64, 2648.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29645,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 2329.49,OTHER, 1296.54, 2877.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29646,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 274.44,,CLAIM ADJUSTMENT 3, 163.86,OTHER, 56.52, 274.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29647,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 200.99,OTHER, 145.30, 331.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29648,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 93.03,OTHER, 53.43, 118.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29649,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 43.50,,CLAIM ADJUSTMENT 3, 22.22,OTHER, 5.74, 43.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29650,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 224.77,OTHER, 146.61, 325.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29651,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 451.07,,CLAIM ADJUSTMENT 3, 251.63,OTHER, 77.72, 451.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29652,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2427.54,,CLAIM ADJUSTMENT 3, 1148.36,OTHER, 241.56, 2427.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29653,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2427.54,,CLAIM ADJUSTMENT 3, 1534.16,OTHER, 572.76, 2427.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29654,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 232.01,OTHER, 122.32, 271.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29655,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 124.43,OTHER, 57.02, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29656,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 120.23,OTHER, 53.32, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29657,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 130.25,OTHER, 62.14, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29658,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 130.25,OTHER, 62.14, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29659,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 5204.99,OTHER, 2293.79, 8355.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29660,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 932.84,OTHER, 274.68, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29661,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 424.57,OTHER, 162.56, 774.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29662,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 334.89,OTHER, 162.56, 594.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29663,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 470.23,,CLAIM ADJUSTMENT 3, 675.88,OTHER, 470.23, 1131.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29664,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 499.77,OTHER, 162.56, 925.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29665,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 499.77,OTHER, 162.56, 925.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29666,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 207.69,OTHER, 148.80, 339.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29667,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 207.69,OTHER, 148.80, 339.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29668,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 103.34,,CLAIM ADJUSTMENT 3, 176.70,OTHER, 103.34, 305.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29669,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 188.66,,CLAIM ADJUSTMENT 3, 596.69,OTHER, 188.66, 1107.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29670,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 188.66,,CLAIM ADJUSTMENT 3, 596.69,OTHER, 188.66, 1107.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29671,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 544.52,,CLAIM ADJUSTMENT 3, 1089.64,OTHER, 544.52, 1926.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29672,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29673,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29674,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29675,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29676,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29677,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29678,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 20.38,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29679,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29680,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 331.58,,CLAIM ADJUSTMENT 3, 579.04,OTHER, 331.58, 1003.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29681,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1095.12,,CLAIM ADJUSTMENT 3, 1525.88,OTHER, 974.17, 2161.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29682,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2484.68,,CLAIM ADJUSTMENT 3, 4097.24,OTHER, 2484.68, 6115.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29683,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2985.38,,CLAIM ADJUSTMENT 3, 4480.28,OTHER, 2930.90, 6504.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29684,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1095.12,,CLAIM ADJUSTMENT 3, 813.44,OTHER, 362.55, 1095.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29685,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1095.12,,CLAIM ADJUSTMENT 3, 4090.68,OTHER, 1095.12, 7048.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29686,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 26.22,,CLAIM ADJUSTMENT 3, 124.21,OTHER, 26.22, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29687,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 26.22,,CLAIM ADJUSTMENT 3, 124.21,OTHER, 26.22, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29688,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2414.09,,CLAIM ADJUSTMENT 3, 1187.28,OTHER, 279.09, 2414.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29689,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1685.72,,CLAIM ADJUSTMENT 3, 803.17,OTHER, 172.67, 1685.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29690,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1685.72,,CLAIM ADJUSTMENT 3, 1733.21,OTHER, 971.08, 2155.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29691,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 1757.99,OTHER, 857.80, 2765.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29692,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 477.65,OTHER, 147.05, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29693,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 497.71,OTHER, 164.28, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29694,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 1514.68,OTHER, 857.80, 2302.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29695,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 2013.65,OTHER, 857.80, 3252.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29696,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 549.67,OTHER, 208.88, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29697,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 578.48,OTHER, 233.61, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29698,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29699,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29700,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 625.15,,CLAIM ADJUSTMENT 3, 718.33,OTHER, 501.48, 1142.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29701,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29702,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2666.24,,CLAIM ADJUSTMENT 3, 1780.93,OTHER, 711.42, 2666.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29703,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 4593.88,,CLAIM ADJUSTMENT 3, 2411.76,OTHER, 661.96, 4593.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29704,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 566.36,,CLAIM ADJUSTMENT 3, 283.55,OTHER, 69.77, 566.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29705,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 566.36,,CLAIM ADJUSTMENT 3, 298.98,OTHER, 83.02, 566.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29706,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 906.71,,CLAIM ADJUSTMENT 3, 482.77,OTHER, 136.45, 906.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29707,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 603.90,OTHER, 244.65, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29708,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 652.77,OTHER, 286.60, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29709,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 754.11,OTHER, 373.59, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29710,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 716.04,OTHER, 340.92, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29711,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 701.64,OTHER, 328.55, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29712,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1148.80,,CLAIM ADJUSTMENT 3, 2366.55,OTHER, 1148.80, 3726.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29713,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1384.25,,CLAIM ADJUSTMENT 3, 623.49,OTHER, 110.84, 1384.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29714,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 198.06,,CLAIM ADJUSTMENT 3, 256.43,OTHER, 159.42, 353.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29715,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1384.25,,CLAIM ADJUSTMENT 3, 637.38,OTHER, 122.76, 1384.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29716,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2350.90,,CLAIM ADJUSTMENT 3, 982.61,OTHER, 122.76, 2350.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29717,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2085.61,,CLAIM ADJUSTMENT 3, 1507.20,OTHER, 654.45, 2085.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29718,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 3410.78,,CLAIM ADJUSTMENT 3, 3143.54,OTHER, 1652.91, 3668.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29719,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 4593.88,,CLAIM ADJUSTMENT 3, 2486.35,OTHER, 725.99, 4593.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29720,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 4593.88,,CLAIM ADJUSTMENT 3, 2559.90,OTHER, 789.14, 4593.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29721,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29722,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 539.71,,CLAIM ADJUSTMENT 3, 1667.02,OTHER, 539.71, 2808.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29723,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 3135.31,,CLAIM ADJUSTMENT 3, 1786.42,OTHER, 572.31, 3135.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29724,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5153.51,,CLAIM ADJUSTMENT 3, 3662.54,OTHER, 1564.15, 5153.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29725,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1963.90,,CLAIM ADJUSTMENT 3, 889.66,OTHER, 161.63, 1963.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29726,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 191.60,,CLAIM ADJUSTMENT 3, 242.39,OTHER, 173.27, 394.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29727,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 191.60,,CLAIM ADJUSTMENT 3, 242.39,OTHER, 173.27, 394.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29728,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2085.61,,CLAIM ADJUSTMENT 3, 2146.09,OTHER, 1202.92, 2669.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29729,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 377.59,,CLAIM ADJUSTMENT 3, 199.77,OTHER, 96.75, 377.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29730,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 657.86,,CLAIM ADJUSTMENT 3, 266.50,OTHER, 96.75, 657.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29731,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1965.95,,CLAIM ADJUSTMENT 3, 2146.91,OTHER, 1478.34, 3369.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29732,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1965.95,,CLAIM ADJUSTMENT 3, 2146.91,OTHER, 1478.34, 3369.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29733,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29734,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29735,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29736,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 4781.78,,CLAIM ADJUSTMENT 3, 2579.17,OTHER, 748.07, 4781.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29737,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 146.68,,CLAIM ADJUSTMENT 3, 162.43,OTHER, 112.28, 255.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29738,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 146.68,,CLAIM ADJUSTMENT 3, 145.32,OTHER, 97.21, 221.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29739,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 191.60,,CLAIM ADJUSTMENT 3, 116.13,OTHER, 62.09, 191.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29740,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 76.24,OTHER, 51.17, 116.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29741,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 124.60,OTHER, 86.34, 208.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29742,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29743,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 62.55,OTHER, 36.98, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29744,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29745,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 99.80,OTHER, 58.91, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29746,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29747,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 161.46,OTHER, 113.20, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29748,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29749,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 62.55,OTHER, 36.98, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29750,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29751,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 171.96,OTHER, 122.45, 279.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29752,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29753,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 127.74,OTHER, 86.34, 215.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29754,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29755,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 189.58,OTHER, 137.97, 314.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29756,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29757,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 116.92,OTHER, 84.85, 193.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29758,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29759,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 299.54,OTHER, 138.19, 535.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29760,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29761,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 221.04,OTHER, 138.19, 377.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29762,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29763,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 177.44,OTHER, 127.28, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29764,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29765,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 71.21,OTHER, 44.60, 101.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29766,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29767,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 193.56,OTHER, 86.34, 347.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29768,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29769,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 223.50,OTHER, 86.34, 407.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29770,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1313.91,OTHER, 283.82, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29771,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1313.91,OTHER, 283.82, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29772,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29773,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29774,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1196.04,OTHER, 432.18, 2193.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29775,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1196.04,OTHER, 432.18, 2193.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29776,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29777,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29778,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1545.39,OTHER, 485.27, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29779,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1545.39,OTHER, 485.27, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29780,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29781,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29782,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.20,OTHER, 283.82, 1781.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29783,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29784,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 691.35,OTHER, 432.18, 1180.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29785,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29786,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 887.08,OTHER, 485.27, 1548.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29787,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29788,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 901.22,OTHER, 283.82, 1673.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29789,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 901.22,OTHER, 283.82, 1673.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29790,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29791,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29792,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1055.93,OTHER, 432.18, 1912.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29793,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1302.68,OTHER, 432.18, 2407.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29794,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29795,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29796,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 513.03,OTHER, 350.02, 797.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29797,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29798,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1290.59,OTHER, 283.82, 2454.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29799,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29800,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1374.81,OTHER, 432.18, 2552.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29801,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29802,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1265.96,OTHER, 485.27, 2308.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29803,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29804,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1076.14,OTHER, 495.38, 1923.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29805,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1076.14,OTHER, 495.38, 1923.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29806,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1076.14,OTHER, 495.38, 1923.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29807,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29808,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29809,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29810,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1270.81,OTHER, 495.38, 2313.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29811,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29812,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1681.52,OTHER, 779.04, 3002.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29813,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29814,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1224.87,OTHER, 508.57, 2215.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29815,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29816,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 1324.21,OTHER, 616.91, 2362.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29817,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 438.95,OTHER, 187.68, 616.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29818,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1532.99,OTHER, 779.04, 2704.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29819,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29820,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1233.59,OTHER, 508.57, 2232.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29821,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29822,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 1256.33,OTHER, 616.91, 2226.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29823,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 438.95,OTHER, 187.68, 616.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29824,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1461.09,OTHER, 779.04, 2560.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29825,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29826,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1413.66,OTHER, 508.57, 2594.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29827,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29828,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2181.19,OTHER, 779.04, 4005.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29829,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2181.19,OTHER, 779.04, 4005.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29830,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29831,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29832,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29833,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29834,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29835,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29836,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29837,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29838,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29839,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29840,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29841,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29842,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29843,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29844,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29845,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29846,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 242.05,OTHER, 86.34, 444.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29847,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 243.52,OTHER, 86.34, 447.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29848,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29849,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29850,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 214.14,OTHER, 138.19, 363.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29851,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 240.03,OTHER, 138.19, 415.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29852,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29853,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29854,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 248.87,OTHER, 138.19, 433.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29855,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29856,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 165.10,OTHER, 86.34, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29857,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29858,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 62.55,OTHER, 36.98, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29859,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29860,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1211.40,OTHER, 283.82, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29861,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1211.40,OTHER, 283.82, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29862,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1211.40,OTHER, 283.82, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29863,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29864,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29865,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1356.87,OTHER, 432.18, 2737.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29866,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1356.87,OTHER, 432.18, 2737.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29867,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29868,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1817.25,OTHER, 485.27, 3415.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29869,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29870,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 1171.85,OTHER, 117.71, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29871,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 1171.85,OTHER, 117.71, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29872,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 1171.85,OTHER, 117.71, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29873,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 209.22,OTHER, 117.71, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29874,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 209.22,OTHER, 117.71, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29875,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 209.22,OTHER, 117.71, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29876,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29877,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29878,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29879,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29880,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29881,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29882,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29883,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29884,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29885,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29886,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29887,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29888,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29889,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.01,OTHER, 86.34, 297.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29890,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.01,OTHER, 86.34, 297.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29891,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29892,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29893,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 247.65,OTHER, 138.19, 430.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29894,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29895,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 350.60,OTHER, 138.19, 637.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29896,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29897,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 382.63,OTHER, 138.19, 701.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29898,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29899,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 293.50,OTHER, 138.19, 522.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29900,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29901,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 265.86,OTHER, 138.19, 467.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29902,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29903,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 161.46,OTHER, 113.20, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29904,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29905,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 142.64,OTHER, 86.34, 245.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29906,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29907,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 63.06,OTHER, 36.98, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29908,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 163.44,OTHER, 113.20, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29909,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 96.05,OTHER, 37.54, 146.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29910,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 259.24,OTHER, 138.19, 454.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29911,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29912,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 166.91,OTHER, 118.00, 268.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29913,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29914,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 407.08,OTHER, 138.19, 750.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29915,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29916,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1459.38,OTHER, 283.82, 2793.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29917,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1459.38,OTHER, 283.82, 2793.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29918,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1459.38,OTHER, 283.82, 2793.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29919,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29920,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29921,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29922,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 664.89,OTHER, 483.75, 1102.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29923,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29924,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1649.11,OTHER, 283.82, 3173.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29925,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1649.11,OTHER, 283.82, 3173.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29926,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29927,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29928,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1665.51,OTHER, 432.18, 3136.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29929,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29930,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1439.18,OTHER, 283.82, 2752.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29931,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29932,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1652.58,OTHER, 432.18, 3110.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29933,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29934,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1580.48,OTHER, 485.27, 2940.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29935,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29936,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1712.29,OTHER, 508.57, 3193.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29937,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29938,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1894.78,OTHER, 508.57, 3559.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29939,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29940,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1677.93,OTHER, 508.57, 3124.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29941,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29942,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2119.80,OTHER, 779.04, 3881.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29943,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29944,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2539.54,OTHER, 779.04, 4724.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29945,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29946,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2390.20,OTHER, 779.04, 4424.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29947,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29948,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29949,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29950,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29951,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 236.81,OTHER, 138.19, 409.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29952,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29953,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 193.87,OTHER, 138.19, 323.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29954,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29955,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1261.16,OTHER, 283.82, 2395.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29956,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1261.16,OTHER, 283.82, 2395.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29957,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29958,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29959,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1256.10,OTHER, 432.18, 2314.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29960,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29961,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 894.65,OTHER, 485.27, 1563.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29962,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29963,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1751.53,OTHER, 508.57, 3272.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29964,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29965,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2629.35,OTHER, 779.04, 4904.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29966,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29967,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29968,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29969,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29970,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29971,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29972,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 29973,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 164.19,OTHER, 86.34, 288.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29974,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29975,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 224.35,OTHER, 86.34, 408.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29976,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29977,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 208.71,OTHER, 86.34, 377.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29978,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 208.71,OTHER, 86.34, 377.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29979,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 215.71,OTHER, 86.34, 391.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29980,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29981,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29982,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29983,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 149.11,OTHER, 86.34, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29984,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 149.11,OTHER, 86.34, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29985,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 149.11,OTHER, 86.34, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29986,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29987,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29988,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29989,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 175.84,OTHER, 86.34, 311.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29990,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.06,OTHER, 86.34, 298.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29991,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.06,OTHER, 86.34, 298.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29992,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29993,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29994,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29995,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 235.06,OTHER, 138.19, 405.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29996,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 235.06,OTHER, 138.19, 405.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29997,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 240.36,OTHER, 138.19, 416.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29998,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 29999,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30000,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30001,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 219.70,OTHER, 86.34, 399.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30002,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 214.45,OTHER, 86.34, 389.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30003,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 214.45,OTHER, 86.34, 389.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30004,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30005,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30006,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30007,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 206.56,OTHER, 86.34, 373.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30008,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 211.81,OTHER, 86.34, 383.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30009,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 206.56,OTHER, 86.34, 373.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30010,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30011,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30012,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30013,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 230.04,OTHER, 86.34, 420.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30014,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 223.50,OTHER, 86.34, 407.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30015,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30016,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30017,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30018,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 230.83,OTHER, 86.34, 421.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30019,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 230.83,OTHER, 86.34, 421.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30020,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 237.37,OTHER, 86.34, 435.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30021,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30022,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30023,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30024,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 99.80,OTHER, 58.91, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30025,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 125.68,OTHER, 81.70, 186.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30026,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 99.80,OTHER, 58.91, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30027,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30028,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30029,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30030,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 213.73,OTHER, 86.34, 387.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30031,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 207.73,OTHER, 86.34, 375.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30032,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 207.74,OTHER, 86.34, 375.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30033,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30034,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30035,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30036,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 238.18,OTHER, 86.34, 436.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30037,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 243.44,OTHER, 86.34, 447.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30038,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 238.18,OTHER, 86.34, 436.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30039,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30040,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30041,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30042,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 238.48,OTHER, 138.19, 412.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30043,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 231.94,OTHER, 138.19, 399.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30044,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 231.94,OTHER, 138.19, 399.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30045,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30046,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30047,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30048,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 220.36,OTHER, 86.34, 400.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30049,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 220.42,OTHER, 86.34, 401.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30050,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 225.67,OTHER, 86.34, 411.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30051,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30052,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30053,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30054,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30055,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 174.69,OTHER, 86.34, 309.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30056,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30057,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30058,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30059,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30060,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30061,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30062,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30063,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30064,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30065,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30066,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30067,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30068,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30069,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30070,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30071,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30072,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30073,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30074,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30075,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30076,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30077,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30078,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30079,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30080,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30081,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1061.06,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30082,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30083,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30084,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30085,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30086,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30087,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30088,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30089,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30090,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30091,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30092,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30093,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30094,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30095,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30096,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30097,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30098,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30099,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30100,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30101,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30102,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30103,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30104,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30105,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30106,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30107,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30108,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30109,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1484.34,OTHER, 432.18, 2772.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30110,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1484.34,OTHER, 432.18, 2772.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30111,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30112,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30113,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30114,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30115,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30116,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30117,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30118,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1055.55,OTHER, 508.57, 1875.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30119,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30120,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1797.05,OTHER, 779.04, 3234.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30121,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1797.05,OTHER, 779.04, 3234.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30122,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1797.05,OTHER, 779.04, 3234.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30123,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30124,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30125,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30126,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30127,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30128,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30129,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30130,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30131,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30132,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30133,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30134,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30135,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30136,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30137,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30138,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30139,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30140,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30141,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30142,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30143,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30144,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30145,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30146,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30147,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30148,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30149,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30150,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30151,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30152,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30153,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30154,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30155,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30156,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30157,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30158,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1450.34,OTHER, 779.04, 2538.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30159,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1450.34,OTHER, 779.04, 2538.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30160,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30161,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30162,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30163,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30164,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30165,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30166,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 196.99,OTHER, 88.46, 353.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30167,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 196.99,OTHER, 88.46, 353.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30168,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 196.99,OTHER, 88.46, 353.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30169,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30170,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30171,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30172,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30173,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30174,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30175,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30176,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30177,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30178,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30179,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30180,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30181,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 234.40,OTHER, 146.51, 446.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30182,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 234.40,OTHER, 146.51, 446.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30183,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 96.05,OTHER, 37.54, 146.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30184,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 96.05,OTHER, 37.54, 146.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30185,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 202.98,OTHER, 88.46, 365.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30186,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 202.98,OTHER, 88.46, 365.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30187,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 208.23,OTHER, 88.46, 375.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30188,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30189,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30190,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30191,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 210.73,OTHER, 86.34, 381.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30192,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 204.73,OTHER, 86.34, 369.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30193,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 204.73,OTHER, 86.34, 369.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30194,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30195,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30196,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30197,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 269.16,OTHER, 138.19, 474.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30198,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 274.41,OTHER, 138.19, 484.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30199,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 269.16,OTHER, 138.19, 474.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30200,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30201,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30202,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30203,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 402.07,OTHER, 138.19, 740.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30204,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 395.36,OTHER, 138.19, 727.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30205,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 395.36,OTHER, 138.19, 727.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30206,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30207,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30208,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30209,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 153.37,OTHER, 86.34, 266.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30210,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30211,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 243.07,OTHER, 86.34, 446.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30212,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 237.82,OTHER, 86.34, 436.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30213,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 237.82,OTHER, 86.34, 436.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30214,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30215,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30216,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30217,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 74.90,OTHER, 36.98, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30218,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 74.90,OTHER, 36.98, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30219,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 116.89,OTHER, 73.96, 168.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30220,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30221,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30222,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30223,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 218.95,OTHER, 138.19, 373.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30224,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 218.95,OTHER, 138.19, 373.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30225,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 225.30,OTHER, 138.19, 386.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30226,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30227,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30228,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30229,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 243.37,OTHER, 138.19, 422.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30230,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 236.76,OTHER, 138.19, 409.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30231,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 236.76,OTHER, 138.19, 409.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30232,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30233,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30234,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30235,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 186.56,OTHER, 86.34, 333.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30236,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 186.56,OTHER, 86.34, 333.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30237,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30238,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30239,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 250.19,OTHER, 86.34, 460.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30240,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 244.84,OTHER, 86.34, 450.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30241,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 244.94,OTHER, 86.34, 450.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30242,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30243,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30244,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30245,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 134.33,OTHER, 86.34, 228.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30246,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 134.33,OTHER, 86.34, 228.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30247,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 134.33,OTHER, 86.34, 228.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30248,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30249,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30250,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30251,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30252,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30253,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30254,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30255,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30256,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30257,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30258,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30259,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 179.26,OTHER, 86.34, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30260,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30261,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30262,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30263,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30264,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30265,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30266,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30267,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30268,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30269,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30270,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30271,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30272,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30273,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30274,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30275,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30276,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1193.14,OTHER, 283.82, 2258.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30277,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30278,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30279,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30280,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30281,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30282,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30283,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30284,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30285,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30286,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30287,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30288,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30289,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30290,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30291,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30292,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30293,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30294,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30295,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30296,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30297,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30298,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30299,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30300,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30301,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1435.02,OTHER, 432.18, 2673.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30302,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1428.39,OTHER, 432.18, 2660.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30303,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1428.39,OTHER, 432.18, 2660.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30304,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30305,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30306,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30307,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30308,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30309,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30310,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30311,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30312,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30313,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 796.22,OTHER, 495.38, 1361.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30314,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 796.22,OTHER, 495.38, 1361.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30315,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30316,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30317,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30318,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30319,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30320,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30321,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30322,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30323,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30324,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30325,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30326,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30327,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30328,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30329,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1953.37,OTHER, 779.04, 3547.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30330,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1953.37,OTHER, 779.04, 3547.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30331,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30332,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30333,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30334,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30335,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30336,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30337,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30338,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30339,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30340,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30341,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30342,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30343,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30344,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30345,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30346,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30347,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30348,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30349,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30350,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30351,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30352,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30353,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30354,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30355,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30356,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30357,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30358,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30359,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30360,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30361,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30362,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30363,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30364,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30365,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30366,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30367,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30368,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30369,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30370,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30371,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30372,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30373,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 102.58,OTHER, 71.38, 162.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30374,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 102.58,OTHER, 71.38, 162.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30375,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30376,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30377,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 172.76,,CLAIM ADJUSTMENT 3, 83.13,OTHER, 36.98, 172.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30378,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 172.76,,CLAIM ADJUSTMENT 3, 105.42,OTHER, 37.54, 172.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30379,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 322.43,OTHER, 138.19, 581.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30380,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 322.43,OTHER, 138.19, 581.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30381,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30382,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30383,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1346.03,OTHER, 283.82, 2565.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30384,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30385,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1544.22,OTHER, 432.18, 2892.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30386,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30387,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1743.20,OTHER, 485.27, 3266.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30388,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30389,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 813.20,,CLAIM ADJUSTMENT 3, 3113.75,OTHER, 813.20, 5860.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30390,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 813.20,,CLAIM ADJUSTMENT 3, 473.04,OTHER, 156.77, 813.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30391,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1743.46,OTHER, 495.38, 3262.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30392,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30393,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 2609.45,OTHER, 276.02, 5105.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30394,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 2609.45,OTHER, 276.02, 5105.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30395,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 265.76,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30396,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 265.76,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30397,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 3021.78,OTHER, 426.91, 5860.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30398,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 3021.78,OTHER, 426.91, 5860.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30399,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 319.65,OTHER, 143.52, 426.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30400,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 319.65,OTHER, 143.52, 426.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30401,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 3385.13,OTHER, 475.94, 6566.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30402,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 3385.13,OTHER, 475.94, 6566.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30403,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 3385.13,OTHER, 475.94, 6566.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30404,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 337.16,OTHER, 143.52, 475.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30405,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 337.16,OTHER, 143.52, 475.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30406,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 337.16,OTHER, 143.52, 475.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30407,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1689.68,OTHER, 508.57, 3148.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30408,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1689.68,OTHER, 508.57, 3148.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30409,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30410,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30411,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1837.06,OTHER, 779.04, 3314.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30412,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30413,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30414,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30415,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30416,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30417,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30418,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 371.17,OTHER, 127.36, 684.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30419,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 371.17,OTHER, 127.36, 684.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30420,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 371.17,OTHER, 127.36, 684.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30421,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 89.21,OTHER, 37.54, 127.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30422,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 89.21,OTHER, 37.54, 127.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30423,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30424,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30425,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 248.14,OTHER, 166.15, 378.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30426,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 230.64,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30427,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 429.88,OTHER, 249.71, 743.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30428,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 132.91,OTHER, 37.54, 249.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30429,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1495.57,OTHER, 495.38, 2764.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30430,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1495.57,OTHER, 495.38, 2764.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30431,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30432,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30433,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30434,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30435,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 385.53,OTHER, 141.55, 706.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30436,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 385.53,OTHER, 141.55, 706.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30437,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 385.53,OTHER, 141.55, 706.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30438,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30439,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30440,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30441,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 286.59,OTHER, 90.89, 531.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30442,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30443,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 281.44,OTHER, 133.37, 501.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30444,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 281.44,OTHER, 133.37, 501.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30445,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 281.44,OTHER, 133.37, 501.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30446,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 288.12,OTHER, 133.37, 514.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30447,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30448,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30449,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30450,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30451,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 503.49,OTHER, 141.55, 942.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30452,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30453,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30454,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30455,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30456,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30457,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30458,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30459,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30460,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30461,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30462,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30463,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 163.97,,CLAIM ADJUSTMENT 3, 468.07,OTHER, 163.97, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30464,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 163.97,,CLAIM ADJUSTMENT 3, 200.02,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30465,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30466,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30467,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30468,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30469,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30470,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30471,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30472,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30473,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30474,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30475,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 414.50,OTHER, 141.55, 764.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30476,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30477,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 214.87,OTHER, 133.37, 367.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30478,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 163.37,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30479,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 408.73,OTHER, 141.55, 752.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30480,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30481,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 507.55,OTHER, 141.55, 950.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30482,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30483,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 775.60,OTHER, 90.89, 1513.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30484,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30485,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 290.56,OTHER, 133.37, 519.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30486,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30487,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.77,OTHER, 141.55, 774.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30488,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30489,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 471.58,OTHER, 141.55, 878.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30490,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 471.58,OTHER, 141.55, 878.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30491,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 471.58,OTHER, 141.55, 878.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30492,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30493,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30494,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30495,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 322.12,OTHER, 90.89, 613.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30496,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 322.12,OTHER, 90.89, 613.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30497,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30498,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30499,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 408.48,OTHER, 141.55, 752.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30500,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30501,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 813.95,OTHER, 137.10, 1568.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30502,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 526.64,OTHER, 137.10, 991.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30503,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 526.64,OTHER, 137.10, 991.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30504,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 190.42,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30505,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 190.42,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30506,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 190.42,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30507,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30508,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 300.33,OTHER, 133.37, 539.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30509,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30510,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30511,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30512,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30513,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30514,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30515,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30516,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30517,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30518,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30519,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30520,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30521,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30522,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30523,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30524,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30525,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30526,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30527,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30528,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30529,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30530,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30531,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30532,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30533,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30534,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30535,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30536,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30537,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 34.54,,CLAIM ADJUSTMENT 3, 78.82,OTHER, 21.15, 181.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30538,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30539,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30540,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30541,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30542,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30543,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30544,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30545,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30546,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 281.03,OTHER, 175.87, 480.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30547,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 281.03,OTHER, 175.87, 480.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30548,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 281.03,OTHER, 175.87, 480.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30549,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 198.15,OTHER, 99.36, 230.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30550,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 198.15,OTHER, 99.36, 230.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30551,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30552,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30553,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30554,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30555,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 235.21,OTHER, 81.44, 588.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30556,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 235.21,OTHER, 81.44, 588.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30557,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 235.21,OTHER, 81.44, 588.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30558,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30559,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30560,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30561,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30562,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30563,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30564,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30565,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 116.40,OTHER, 73.53, 167.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30566,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 70.96,OTHER, 18.55, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30567,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 232.03,,CLAIM ADJUSTMENT 3, 414.07,OTHER, 232.03, 720.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30568,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 158.67,OTHER, 84.28, 343.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30569,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 158.67,OTHER, 84.28, 343.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30570,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 59.28,OTHER, 18.55, 105.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30571,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 59.28,OTHER, 18.55, 105.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30572,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 42.36,,CLAIM ADJUSTMENT 3, 154.63,OTHER, 42.36, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30573,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 204.30,OTHER, 138.19, 343.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30574,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 70.96,OTHER, 18.55, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30575,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 660.83,OTHER, 156.82, 1251.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30576,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 660.83,OTHER, 156.82, 1251.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30577,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 171.75,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30578,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 171.75,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30579,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 533.81,OTHER, 206.35, 972.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30580,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 533.81,OTHER, 206.35, 972.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30581,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 189.44,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30582,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 189.44,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30583,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 320.35,,CLAIM ADJUSTMENT 3, 757.92,OTHER, 320.35, 1367.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30584,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 320.35,,CLAIM ADJUSTMENT 3, 230.15,OTHER, 99.36, 320.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30585,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 322.62,,CLAIM ADJUSTMENT 3, 899.81,OTHER, 322.62, 1651.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30586,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 322.62,,CLAIM ADJUSTMENT 3, 230.96,OTHER, 99.36, 322.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30587,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 548.80,,CLAIM ADJUSTMENT 3, 1092.65,OTHER, 548.80, 1930.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30588,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 548.80,,CLAIM ADJUSTMENT 3, 311.74,OTHER, 99.36, 548.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30589,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 864.03,OTHER, 423.08, 1531.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30590,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 266.84,OTHER, 99.36, 423.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30591,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 344.89,OTHER, 215.00, 490.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30592,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 266.84,OTHER, 99.36, 423.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30593,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 830.31,OTHER, 410.92, 1470.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30594,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 262.50,OTHER, 99.36, 410.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30595,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 1103.77,OTHER, 410.92, 2018.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30596,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 262.50,OTHER, 99.36, 410.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30597,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 1111.16,OTHER, 359.95, 2058.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30598,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 244.29,OTHER, 99.36, 359.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30599,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 624.07,OTHER, 359.95, 1080.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30600,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 244.29,OTHER, 99.36, 359.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30601,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 672.34,OTHER, 360.01, 1177.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30602,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30603,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 559.38,OTHER, 360.01, 950.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30604,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30605,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 1228.06,OTHER, 360.01, 2292.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30606,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30607,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 1294.05,OTHER, 360.01, 2425.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30608,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30609,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30610,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30611,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 1149.19,OTHER, 775.51, 1767.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30612,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 1149.19,OTHER, 775.51, 1767.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30613,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 518.51,OTHER, 99.36, 1127.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30614,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 518.51,OTHER, 99.36, 1127.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30615,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 2267.81,OTHER, 1127.76, 4012.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30616,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 518.51,OTHER, 99.36, 1127.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30617,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 815.01,OTHER, 444.92, 1423.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30618,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 815.01,OTHER, 444.92, 1423.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30619,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 274.64,OTHER, 99.36, 444.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30620,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 274.64,OTHER, 99.36, 444.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30621,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.54,,CLAIM ADJUSTMENT 3, 635.79,OTHER, 283.54, 1140.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30622,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 283.54,,CLAIM ADJUSTMENT 3, 217.00,OTHER, 99.36, 283.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30623,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 300.36,,CLAIM ADJUSTMENT 3, 984.09,OTHER, 300.36, 1831.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30624,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 300.36,,CLAIM ADJUSTMENT 3, 223.01,OTHER, 99.36, 300.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30625,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 443.12,,CLAIM ADJUSTMENT 3, 1050.06,OTHER, 443.12, 1895.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30626,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 443.12,,CLAIM ADJUSTMENT 3, 274.00,OTHER, 99.36, 443.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30627,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 742.64,,CLAIM ADJUSTMENT 3, 684.67,OTHER, 447.20, 1019.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30628,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 742.64,,CLAIM ADJUSTMENT 3, 380.97,OTHER, 99.36, 742.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30629,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 2685.69,OTHER, 1509.32, 4668.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30630,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 744.80,OTHER, 176.64, 1509.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30631,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 2768.70,OTHER, 1509.32, 4835.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30632,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 744.80,OTHER, 176.64, 1509.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30633,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.78,,CLAIM ADJUSTMENT 3, 34.30,OTHER, 19.78, 59.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30634,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.18,,CLAIM ADJUSTMENT 3, 32.49,OTHER, 12.18, 59.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30635,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30636,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 10.09,,CLAIM ADJUSTMENT 3, 70.69,OTHER, 10.09, 137.05,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30637,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 15.20,,CLAIM ADJUSTMENT 3, 122.16,OTHER, 15.20, 237.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30638,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.28,,CLAIM ADJUSTMENT 3, 97.60,OTHER, 19.28, 186.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30639,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.28,,CLAIM ADJUSTMENT 3, 97.60,OTHER, 19.28, 186.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30640,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.50,,CLAIM ADJUSTMENT 3, 83.55,OTHER, 12.50, 161.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30641,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.50,,CLAIM ADJUSTMENT 3, 83.55,OTHER, 12.50, 161.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30642,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 68.59,,CLAIM ADJUSTMENT 3, 155.85,OTHER, 68.59, 280.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30643,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.76,,CLAIM ADJUSTMENT 3, 78.98,OTHER, 11.76, 152.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30644,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 22.37,,CLAIM ADJUSTMENT 3, 69.30,OTHER, 22.37, 128.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30645,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 46.28,,CLAIM ADJUSTMENT 3, 229.30,OTHER, 46.28, 438.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30646,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 88.95,OTHER, 20.98, 172.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30647,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 88.95,OTHER, 20.98, 172.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30648,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.13,,CLAIM ADJUSTMENT 3, 53.39,OTHER, 19.13, 98.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30649,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.13,,CLAIM ADJUSTMENT 3, 53.39,OTHER, 19.13, 98.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30650,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.50,,CLAIM ADJUSTMENT 3, 80.17,OTHER, 19.50, 151.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30651,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 31.20,,CLAIM ADJUSTMENT 3, 54.61,OTHER, 31.20, 94.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30652,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 80.03,OTHER, 19.08, 151.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30653,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 79.17,OTHER, 19.08, 149.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30654,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.52,,CLAIM ADJUSTMENT 3, 63.95,OTHER, 9.52, 123.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30655,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 22.37,,CLAIM ADJUSTMENT 3, 28.28,OTHER, 20.21, 46.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30656,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 83.69,OTHER, 19.08, 158.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30657,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 22.03,,CLAIM ADJUSTMENT 3, 53.47,OTHER, 22.03, 96.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30658,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 79.81,OTHER, 19.08, 151.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30659,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.78,,CLAIM ADJUSTMENT 3, 44.64,OTHER, 19.78, 80.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30660,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.78,,CLAIM ADJUSTMENT 3, 145.91,OTHER, 19.78, 283.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30661,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.36,,CLAIM ADJUSTMENT 3, 64.76,OTHER, 20.36, 120.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30662,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.16,,CLAIM ADJUSTMENT 3, 121.34,OTHER, 17.16, 235.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30663,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.50,,CLAIM ADJUSTMENT 3, 84.76,OTHER, 19.50, 160.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30664,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 32.53,,CLAIM ADJUSTMENT 3, 134.69,OTHER, 32.53, 254.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30665,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 26.84,,CLAIM ADJUSTMENT 3, 90.91,OTHER, 26.84, 169.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30666,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 56.90,OTHER, 10.75, 186.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30667,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 56.90,OTHER, 10.75, 186.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30668,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 23.85,OTHER, 17.20, 39.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30669,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 23.85,OTHER, 17.20, 39.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30670,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30671,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30672,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30673,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30674,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30675,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30676,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30677,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30678,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30679,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30680,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30681,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30682,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30683,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30684,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30685,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30686,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30687,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30688,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30689,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 4.56,,CLAIM ADJUSTMENT 3, 34.88,OTHER, 4.56, 67.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30690,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 4.56,,CLAIM ADJUSTMENT 3, 34.88,OTHER, 4.56, 67.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30691,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 4.56,,CLAIM ADJUSTMENT 3, 34.88,OTHER, 4.56, 67.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30692,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 20.93,OTHER, 3.24, 40.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30693,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 20.93,OTHER, 3.24, 40.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30694,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 20.93,OTHER, 3.24, 40.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30695,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 7.12,OTHER, 3.24, 12.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30696,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 3.12,,CLAIM ADJUSTMENT 3, 8.07,OTHER, 3.12, 14.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30697,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 33.86,OTHER, 12.40, 62.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30698,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 33.86,OTHER, 12.40, 62.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30699,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 75.71,OTHER, 12.40, 146.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30700,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 75.71,OTHER, 12.40, 146.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30701,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 105.66,,CLAIM ADJUSTMENT 3, 145.60,OTHER, 105.66, 241.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30702,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 105.66,,CLAIM ADJUSTMENT 3, 145.60,OTHER, 105.66, 241.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30703,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 94.12,,CLAIM ADJUSTMENT 3, 262.66,OTHER, 94.12, 482.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30704,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 131.99,,CLAIM ADJUSTMENT 3, 428.98,OTHER, 131.99, 797.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30705,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30706,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30707,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 30708,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.50,,CLAIM ADJUSTMENT 3, 53.15,OTHER, 6.50, 103.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30709,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.76,,CLAIM ADJUSTMENT 3, 38.90,OTHER, 11.76, 72.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30710,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 55.61,,CLAIM ADJUSTMENT 3, 146.83,OTHER, 55.61, 268.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30711,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.13,,CLAIM ADJUSTMENT 3, 20.13,OTHER, 7.13, 37.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30712,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.13,,CLAIM ADJUSTMENT 3, 20.13,OTHER, 7.13, 37.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30713,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.21,,CLAIM ADJUSTMENT 3, 28.92,OTHER, 11.21, 52.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30714,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.21,,CLAIM ADJUSTMENT 3, 28.92,OTHER, 11.21, 52.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30715,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 8.33,,CLAIM ADJUSTMENT 3, 60.58,OTHER, 8.33, 117.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30716,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 8.33,,CLAIM ADJUSTMENT 3, 60.58,OTHER, 8.33, 117.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30717,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 50.88,OTHER, 13.98, 95.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30718,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.36,,CLAIM ADJUSTMENT 3, 71.06,OTHER, 19.36, 133.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30719,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.82,,CLAIM ADJUSTMENT 3, 109.86,OTHER, 20.82, 210.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30720,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.14,,CLAIM ADJUSTMENT 3, 80.16,OTHER, 24.14, 149.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30721,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.14,,CLAIM ADJUSTMENT 3, 80.16,OTHER, 24.14, 149.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30722,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 63.10,OTHER, 20.98, 116.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30723,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 63.10,OTHER, 20.98, 116.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30724,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.34,,CLAIM ADJUSTMENT 3, 50.79,OTHER, 9.34, 97.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30725,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.34,,CLAIM ADJUSTMENT 3, 50.79,OTHER, 9.34, 97.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30726,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 42.16,,CLAIM ADJUSTMENT 3, 100.38,OTHER, 42.16, 181.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30727,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 46.34,,CLAIM ADJUSTMENT 3, 121.92,OTHER, 46.34, 222.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30728,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 30.37,,CLAIM ADJUSTMENT 3, 50.20,OTHER, 30.37, 86.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30729,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 27.31,,CLAIM ADJUSTMENT 3, 116.31,OTHER, 27.31, 220.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30730,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 14.24,,CLAIM ADJUSTMENT 3, 49.78,OTHER, 14.24, 93.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30731,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 23.30,,CLAIM ADJUSTMENT 3, 63.44,OTHER, 23.30, 116.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30732,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.22,,CLAIM ADJUSTMENT 3, 36.36,OTHER, 7.22, 69.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30733,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.22,,CLAIM ADJUSTMENT 3, 36.36,OTHER, 7.22, 69.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30734,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.22,,CLAIM ADJUSTMENT 3, 33.07,OTHER, 7.22, 62.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30735,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.31,,CLAIM ADJUSTMENT 3, 19.33,OTHER, 6.31, 35.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30736,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.38,,CLAIM ADJUSTMENT 3, 33.34,OTHER, 6.38, 63.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30737,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 22.92,,CLAIM ADJUSTMENT 3, 56.73,OTHER, 22.92, 102.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30738,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 42.62,,CLAIM ADJUSTMENT 3, 126.67,OTHER, 42.62, 244.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30739,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 42.62,,CLAIM ADJUSTMENT 3, 126.67,OTHER, 42.62, 244.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30740,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 42.62,,CLAIM ADJUSTMENT 3, 126.67,OTHER, 42.62, 244.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30741,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 38.58,,CLAIM ADJUSTMENT 3, 123.66,OTHER, 38.58, 229.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30742,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.43,,CLAIM ADJUSTMENT 3, 34.08,OTHER, 7.43, 64.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30743,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.43,,CLAIM ADJUSTMENT 3, 34.08,OTHER, 7.43, 64.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30744,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.43,,CLAIM ADJUSTMENT 3, 34.08,OTHER, 7.43, 64.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30745,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.70,,CLAIM ADJUSTMENT 3, 69.24,OTHER, 19.70, 129.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30746,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 8.69,,CLAIM ADJUSTMENT 3, 49.97,OTHER, 8.69, 96.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30747,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.58,,CLAIM ADJUSTMENT 3, 44.47,OTHER, 18.58, 80.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30748,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.74,,CLAIM ADJUSTMENT 3, 65.14,OTHER, 17.74, 122.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30749,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 27.30,,CLAIM ADJUSTMENT 3, 87.25,OTHER, 27.30, 162.05,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30750,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 27.30,,CLAIM ADJUSTMENT 3, 87.25,OTHER, 27.30, 162.05,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30751,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.29,,CLAIM ADJUSTMENT 3, 59.01,OTHER, 24.29, 106.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30752,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 36.36,,CLAIM ADJUSTMENT 3, 127.93,OTHER, 36.36, 240.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30753,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 36.36,,CLAIM ADJUSTMENT 3, 127.93,OTHER, 36.36, 240.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30754,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 56.46,OTHER, 15.47, 105.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30755,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 8.28,,CLAIM ADJUSTMENT 3, 13.69,OTHER, 8.28, 23.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30756,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.87,,CLAIM ADJUSTMENT 3, 73.71,OTHER, 17.87, 139.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30757,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.06,,CLAIM ADJUSTMENT 3, 87.73,OTHER, 24.06, 164.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30758,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.06,,CLAIM ADJUSTMENT 3, 87.73,OTHER, 24.06, 164.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30759,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 23.47,,CLAIM ADJUSTMENT 3, 66.31,OTHER, 23.47, 121.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30760,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 23.47,,CLAIM ADJUSTMENT 3, 66.31,OTHER, 23.47, 121.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30761,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 34.69,,CLAIM ADJUSTMENT 3, 190.19,OTHER, 34.69, 365.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30762,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 34.69,,CLAIM ADJUSTMENT 3, 214.01,OTHER, 34.69, 412.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30763,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.37,,CLAIM ADJUSTMENT 3, 47.49,OTHER, 9.37, 90.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30764,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.37,,CLAIM ADJUSTMENT 3, 47.49,OTHER, 9.37, 90.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30765,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.28,,CLAIM ADJUSTMENT 3, 41.70,OTHER, 19.28, 74.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30766,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.63,,CLAIM ADJUSTMENT 3, 59.73,OTHER, 16.63, 111.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30767,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.37,,CLAIM ADJUSTMENT 3, 31.62,OTHER, 7.37, 59.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30768,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.37,,CLAIM ADJUSTMENT 3, 31.62,OTHER, 7.37, 59.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30769,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.37,,CLAIM ADJUSTMENT 3, 31.62,OTHER, 7.37, 59.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30770,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 39.11,OTHER, 7.46, 74.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30771,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 39.11,OTHER, 7.46, 74.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30772,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.62,,CLAIM ADJUSTMENT 3, 93.47,OTHER, 13.62, 181.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30773,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.62,,CLAIM ADJUSTMENT 3, 93.47,OTHER, 13.62, 181.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30774,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.97,,CLAIM ADJUSTMENT 3, 45.06,OTHER, 16.97, 82.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30775,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 76.21,OTHER, 9.31, 148.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30776,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 21.72,,CLAIM ADJUSTMENT 3, 72.23,OTHER, 21.72, 134.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30777,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 21.72,,CLAIM ADJUSTMENT 3, 72.23,OTHER, 21.72, 134.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30778,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 75.36,OTHER, 26.66, 138.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30779,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 75.36,OTHER, 26.66, 138.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30780,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 36.38,,CLAIM ADJUSTMENT 3, 127.42,OTHER, 36.38, 238.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30781,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 36.38,,CLAIM ADJUSTMENT 3, 127.42,OTHER, 36.38, 238.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30782,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 27.06,,CLAIM ADJUSTMENT 3, 93.87,OTHER, 27.06, 175.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30783,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 40.24,,CLAIM ADJUSTMENT 3, 135.49,OTHER, 40.24, 252.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30784,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 40.24,,CLAIM ADJUSTMENT 3, 135.49,OTHER, 40.24, 252.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30785,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 46.51,,CLAIM ADJUSTMENT 3, 83.83,OTHER, 46.51, 146.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30786,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 34.82,,CLAIM ADJUSTMENT 3, 73.72,OTHER, 34.82, 131.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30787,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 35.93,,CLAIM ADJUSTMENT 3, 75.45,OTHER, 35.93, 134.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30788,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 33.53,,CLAIM ADJUSTMENT 3, 121.64,OTHER, 33.53, 228.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30789,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.34,,CLAIM ADJUSTMENT 3, 69.17,OTHER, 7.34, 135.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30790,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.19,,CLAIM ADJUSTMENT 3, 124.67,OTHER, 24.19, 238.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30791,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.63,,CLAIM ADJUSTMENT 3, 76.46,OTHER, 19.63, 144.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30792,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 21.17,,CLAIM ADJUSTMENT 3, 71.48,OTHER, 21.17, 133.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30793,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30794,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30795,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30796,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30797,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30798,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 23.70,,CLAIM ADJUSTMENT 3, 64.96,OTHER, 23.70, 119.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30799,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.54,,CLAIM ADJUSTMENT 3, 34.98,OTHER, 11.54, 64.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30800,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.54,,CLAIM ADJUSTMENT 3, 203.52,OTHER, 37.54, 390.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30801,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 25.39,,CLAIM ADJUSTMENT 3, 61.71,OTHER, 25.39, 111.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30802,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 25.64,OTHER, 5.66, 48.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30803,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 25.64,OTHER, 5.66, 48.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30804,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 25.64,OTHER, 5.66, 48.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30805,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 28.32,OTHER, 5.66, 54.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30806,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 28.32,OTHER, 5.66, 54.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30807,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 28.32,OTHER, 5.66, 54.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30808,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 14.14,OTHER, 5.66, 25.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30809,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 64.46,OTHER, 6.84, 126.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30810,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 64.46,OTHER, 6.84, 126.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30811,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.97,,CLAIM ADJUSTMENT 3, 57.91,OTHER, 13.97, 109.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30812,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 10.37,,CLAIM ADJUSTMENT 3, 37.55,OTHER, 10.37, 70.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30813,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 26.76,,CLAIM ADJUSTMENT 3, 94.73,OTHER, 26.76, 177.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30814,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 26.76,,CLAIM ADJUSTMENT 3, 94.73,OTHER, 26.76, 177.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30815,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 94.52,OTHER, 26.66, 176.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30816,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 94.52,OTHER, 26.66, 176.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30817,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.12,,CLAIM ADJUSTMENT 3, 67.05,OTHER, 18.12, 125.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30818,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 31.62,,CLAIM ADJUSTMENT 3, 74.92,OTHER, 31.62, 135.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30819,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 48.30,OTHER, 13.98, 90.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30820,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 48.30,OTHER, 13.98, 90.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30821,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 48.30,OTHER, 13.98, 90.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30822,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 25.80,,CLAIM ADJUSTMENT 3, 99.83,OTHER, 25.80, 188.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30823,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30824,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30825,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30826,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30827,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30828,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30829,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.86,,CLAIM ADJUSTMENT 3, 128.28,OTHER, 24.86, 290.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30830,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.86,,CLAIM ADJUSTMENT 3, 128.28,OTHER, 24.86, 290.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30831,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.86,,CLAIM ADJUSTMENT 3, 128.28,OTHER, 24.86, 290.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30832,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 25.93,OTHER, 18.49, 42.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30833,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.46,,CLAIM ADJUSTMENT 3, 69.04,OTHER, 16.46, 130.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30834,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 43.88,OTHER, 9.31, 83.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30835,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 43.88,OTHER, 9.31, 83.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30836,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 43.88,OTHER, 9.31, 83.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30837,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30838,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30839,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30840,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30841,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.66,,CLAIM ADJUSTMENT 3, 70.04,OTHER, 16.66, 132.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30842,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 8.70,,CLAIM ADJUSTMENT 3, 51.00,OTHER, 8.70, 111.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30843,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 8.70,,CLAIM ADJUSTMENT 3, 51.00,OTHER, 8.70, 111.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30844,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.42,,CLAIM ADJUSTMENT 3, 85.45,OTHER, 18.42, 162.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30845,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 28.37,,CLAIM ADJUSTMENT 3, 68.77,OTHER, 28.37, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30846,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.44,,CLAIM ADJUSTMENT 3, 54.77,OTHER, 17.44, 101.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30847,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.44,,CLAIM ADJUSTMENT 3, 54.77,OTHER, 17.44, 101.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30848,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.92,,CLAIM ADJUSTMENT 3, 60.48,OTHER, 9.92, 116.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30849,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.92,,CLAIM ADJUSTMENT 3, 60.48,OTHER, 9.92, 116.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30850,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 66.68,,CLAIM ADJUSTMENT 3, 149.05,OTHER, 66.68, 267.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30851,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 49.24,,CLAIM ADJUSTMENT 3, 43.46,OTHER, 27.95, 63.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30852,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 15.12,,CLAIM ADJUSTMENT 3, 43.01,OTHER, 15.12, 79.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30853,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 15.12,,CLAIM ADJUSTMENT 3, 43.01,OTHER, 15.12, 79.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30854,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.65,,CLAIM ADJUSTMENT 3, 40.64,OTHER, 9.65, 76.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30855,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 34.72,,CLAIM ADJUSTMENT 3, 204.04,OTHER, 34.72, 392.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30856,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 23.41,,CLAIM ADJUSTMENT 3, 57.49,OTHER, 23.41, 104.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30857,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 159.56,OTHER, 24.40, 308.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30858,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 159.56,OTHER, 24.40, 308.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30859,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.60,,CLAIM ADJUSTMENT 3, 74.79,OTHER, 18.60, 163.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30860,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.60,,CLAIM ADJUSTMENT 3, 74.79,OTHER, 18.60, 163.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30861,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 56.53,,CLAIM ADJUSTMENT 3, 120.40,OTHER, 56.53, 214.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30862,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 56.53,,CLAIM ADJUSTMENT 3, 120.40,OTHER, 56.53, 214.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30863,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 30.54,,CLAIM ADJUSTMENT 3, 110.95,OTHER, 30.54, 208.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30864,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.52,,CLAIM ADJUSTMENT 3, 54.17,OTHER, 9.52, 104.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30865,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.82,,CLAIM ADJUSTMENT 3, 44.45,OTHER, 9.82, 84.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30866,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.82,,CLAIM ADJUSTMENT 3, 44.45,OTHER, 9.82, 84.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30867,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.81,,CLAIM ADJUSTMENT 3, 86.15,OTHER, 20.81, 162.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30868,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 59.45,,CLAIM ADJUSTMENT 3, 147.00,OTHER, 59.45, 266.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30869,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 59.45,,CLAIM ADJUSTMENT 3, 147.00,OTHER, 59.45, 266.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30870,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 27.89,,CLAIM ADJUSTMENT 3, 43.75,OTHER, 27.89, 74.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30871,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 28.27,,CLAIM ADJUSTMENT 3, 186.61,OTHER, 28.27, 361.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30872,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 45.87,OTHER, 7.46, 92.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30873,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 45.87,OTHER, 7.46, 92.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30874,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.83,,CLAIM ADJUSTMENT 3, 35.19,OTHER, 6.83, 67.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30875,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.83,,CLAIM ADJUSTMENT 3, 35.19,OTHER, 6.83, 67.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30876,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.85,,CLAIM ADJUSTMENT 3, 28.87,OTHER, 6.85, 54.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30877,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.82,,CLAIM ADJUSTMENT 3, 13.83,OTHER, 6.82, 24.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30878,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 21.01,,CLAIM ADJUSTMENT 3, 45.56,OTHER, 21.01, 81.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30879,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 30.04,,CLAIM ADJUSTMENT 3, 92.72,OTHER, 30.04, 171.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30880,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 30.04,,CLAIM ADJUSTMENT 3, 92.72,OTHER, 30.04, 171.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30881,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 39.19,,CLAIM ADJUSTMENT 3, 102.79,OTHER, 39.19, 187.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30882,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 27.91,,CLAIM ADJUSTMENT 3, 97.17,OTHER, 27.91, 181.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30883,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 26.48,,CLAIM ADJUSTMENT 3, 90.21,OTHER, 26.48, 174.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30884,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 26.48,,CLAIM ADJUSTMENT 3, 90.21,OTHER, 26.48, 174.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30885,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 26.48,,CLAIM ADJUSTMENT 3, 93.39,OTHER, 26.48, 174.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30886,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 24.66,OTHER, 5.28, 46.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30887,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 24.66,OTHER, 5.28, 46.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30888,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 57.84,OTHER, 5.28, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30889,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 57.84,OTHER, 5.28, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30890,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 57.84,OTHER, 5.28, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30891,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.76,,CLAIM ADJUSTMENT 3, 41.90,OTHER, 5.76, 83.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30892,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.76,,CLAIM ADJUSTMENT 3, 41.90,OTHER, 5.76, 83.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30893,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.76,,CLAIM ADJUSTMENT 3, 41.90,OTHER, 5.76, 83.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30894,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 144.06,OTHER, 15.47, 390.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30895,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 144.06,OTHER, 15.47, 390.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30896,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 25.68,,CLAIM ADJUSTMENT 3, 141.59,OTHER, 25.68, 394.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30897,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 25.68,,CLAIM ADJUSTMENT 3, 141.59,OTHER, 25.68, 394.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30898,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 38.44,,CLAIM ADJUSTMENT 3, 136.35,OTHER, 38.44, 255.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30899,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 40.46,,CLAIM ADJUSTMENT 3, 103.27,OTHER, 40.46, 187.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30900,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 31.67,,CLAIM ADJUSTMENT 3, 76.88,OTHER, 31.67, 139.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30901,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 29.15,,CLAIM ADJUSTMENT 3, 178.83,OTHER, 29.15, 344.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30902,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 31.30,,CLAIM ADJUSTMENT 3, 88.43,OTHER, 31.30, 162.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30903,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.92,,CLAIM ADJUSTMENT 3, 30.02,OTHER, 6.92, 56.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30904,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.92,,CLAIM ADJUSTMENT 3, 30.02,OTHER, 6.92, 56.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30905,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.28,,CLAIM ADJUSTMENT 3, 34.17,OTHER, 7.28, 88.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30906,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.28,,CLAIM ADJUSTMENT 3, 34.17,OTHER, 7.28, 88.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30907,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.28,,CLAIM ADJUSTMENT 3, 34.17,OTHER, 7.28, 88.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30908,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 30.61,,CLAIM ADJUSTMENT 3, 180.72,OTHER, 30.61, 348.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30909,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.66,,CLAIM ADJUSTMENT 3, 302.95,OTHER, 11.66, 602.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30910,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 36.67,,CLAIM ADJUSTMENT 3, 81.90,OTHER, 36.67, 146.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30911,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30912,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30913,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30914,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30915,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 30.58,,CLAIM ADJUSTMENT 3, 86.80,OTHER, 30.58, 159.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30916,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 30.58,,CLAIM ADJUSTMENT 3, 86.80,OTHER, 30.58, 159.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30917,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 23.12,,CLAIM ADJUSTMENT 3, 107.35,OTHER, 23.12, 204.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30918,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 23.12,,CLAIM ADJUSTMENT 3, 107.35,OTHER, 23.12, 204.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30919,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.89,,CLAIM ADJUSTMENT 3, 53.27,OTHER, 9.89, 102.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30920,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.89,,CLAIM ADJUSTMENT 3, 53.27,OTHER, 9.89, 102.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30921,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.98,,CLAIM ADJUSTMENT 3, 75.95,OTHER, 12.98, 146.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30922,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.98,,CLAIM ADJUSTMENT 3, 75.95,OTHER, 12.98, 146.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30923,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.98,,CLAIM ADJUSTMENT 3, 75.95,OTHER, 12.98, 146.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30924,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 21.29,,CLAIM ADJUSTMENT 3, 51.95,OTHER, 21.29, 94.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30925,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.19,,CLAIM ADJUSTMENT 3, 73.53,OTHER, 24.19, 136.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30926,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 73.24,,CLAIM ADJUSTMENT 3, 154.17,OTHER, 73.24, 274.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30927,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 73.24,,CLAIM ADJUSTMENT 3, 154.17,OTHER, 73.24, 274.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30928,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.42,,CLAIM ADJUSTMENT 3, 49.79,OTHER, 20.42, 90.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30929,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 38.32,OTHER, 7.46, 73.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30930,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.63,,CLAIM ADJUSTMENT 3, 35.99,OTHER, 7.63, 68.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30931,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.37,,CLAIM ADJUSTMENT 3, 58.51,OTHER, 18.37, 108.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30932,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 8.27,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 8.27, 74.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30933,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.42,,CLAIM ADJUSTMENT 3, 79.41,OTHER, 20.42, 149.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30934,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.42,,CLAIM ADJUSTMENT 3, 79.41,OTHER, 20.42, 149.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30935,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 78.90,OTHER, 24.40, 146.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30936,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 78.90,OTHER, 24.40, 146.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30937,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 22.69,,CLAIM ADJUSTMENT 3, 126.89,OTHER, 22.69, 243.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30938,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.95,,CLAIM ADJUSTMENT 3, 82.99,OTHER, 17.95, 157.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30939,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.95,,CLAIM ADJUSTMENT 3, 82.99,OTHER, 17.95, 157.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30940,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.69,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 5.69, 75.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30941,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.69,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 5.69, 75.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30942,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.69,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 5.69, 75.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30943,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 8.00,,CLAIM ADJUSTMENT 3, 22.60,OTHER, 8.00, 41.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30944,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 8.00,,CLAIM ADJUSTMENT 3, 22.60,OTHER, 8.00, 41.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30945,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.50,,CLAIM ADJUSTMENT 3, 31.87,OTHER, 6.50, 60.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30946,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.32,,CLAIM ADJUSTMENT 3, 39.10,OTHER, 7.32, 74.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30947,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.72,,CLAIM ADJUSTMENT 3, 76.33,OTHER, 16.72, 145.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30948,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.75,,CLAIM ADJUSTMENT 3, 103.71,OTHER, 19.75, 198.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30949,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.40,,CLAIM ADJUSTMENT 3, 56.68,OTHER, 16.40, 105.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30950,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.40,,CLAIM ADJUSTMENT 3, 56.68,OTHER, 16.40, 105.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30951,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.40,,CLAIM ADJUSTMENT 3, 56.68,OTHER, 16.40, 105.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30952,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 29.96, 157.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30953,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 21.67,,CLAIM ADJUSTMENT 3, 97.04,OTHER, 21.67, 184.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30954,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.94,,CLAIM ADJUSTMENT 3, 42.88,OTHER, 6.94, 82.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30955,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.47,,CLAIM ADJUSTMENT 3, 43.80,OTHER, 5.47, 85.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30956,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 17.85,OTHER, 3.41, 34.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30957,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 17.85,OTHER, 3.41, 34.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30958,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 21.46,OTHER, 3.41, 41.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30959,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 21.46,OTHER, 3.41, 41.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30960,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 22.31,OTHER, .01, 84.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30961,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.18,,CLAIM ADJUSTMENT 3, 22.31,OTHER, .01, 84.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30962,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 44.71,OTHER, 9.31, 85.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30963,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.75,,CLAIM ADJUSTMENT 3, 37.65,OTHER, 5.75, 72.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30964,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.75,,CLAIM ADJUSTMENT 3, 37.65,OTHER, 5.75, 72.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30965,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 3.66,,CLAIM ADJUSTMENT 3, 19.92,OTHER, 3.66, 38.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30966,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.46,,CLAIM ADJUSTMENT 3, 32.63,OTHER, 6.46, 62.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30967,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 25.78,,CLAIM ADJUSTMENT 3, 96.77,OTHER, 25.78, 181.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30968,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 33.04,,CLAIM ADJUSTMENT 3, 129.31,OTHER, 33.04, 243.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30969,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.06,,CLAIM ADJUSTMENT 3, 130.54,OTHER, 17.06, 253.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30970,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.93,,CLAIM ADJUSTMENT 3, 98.34,OTHER, 19.93, 187.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30971,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 22.06,,CLAIM ADJUSTMENT 3, 89.00,OTHER, 22.06, 168.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30972,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 14.66,,CLAIM ADJUSTMENT 3, 98.22,OTHER, 14.66, 190.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30973,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.99,,CLAIM ADJUSTMENT 3, 54.63,OTHER, 13.99, 102.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30974,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 27.00,,CLAIM ADJUSTMENT 3, 70.40,OTHER, 27.00, 128.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30975,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 29.86,OTHER, 6.18, 57.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30976,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 29.86,OTHER, 6.18, 57.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30977,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 29.86,OTHER, 6.18, 57.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30978,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30979,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30980,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30981,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30982,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 41.60,OTHER, 6.14, 80.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30983,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 3.89,,CLAIM ADJUSTMENT 3, 26.32,OTHER, 3.89, 50.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30984,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.93,,CLAIM ADJUSTMENT 3, 36.35,OTHER, 7.93, 69.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30985,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 8.65,,CLAIM ADJUSTMENT 3, 61.85,OTHER, 8.65, 166.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30986,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 8.65,,CLAIM ADJUSTMENT 3, 61.85,OTHER, 8.65, 166.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30987,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.26,,CLAIM ADJUSTMENT 3, 76.67,OTHER, 11.26, 148.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30988,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30989,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30990,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30991,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30992,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30993,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30994,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30995,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30996,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30997,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30998,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 30999,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31000,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31001,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31002,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31003,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31004,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31005,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31006,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31007,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31008,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31009,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31010,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31011,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31012,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31013,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31014,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31015,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31016,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31017,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31018,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31019,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31020,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31021,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31022,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31023,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31024,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31025,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31026,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31027,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31028,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31029,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31030,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31031,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31032,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31033,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31034,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31035,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31036,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31037,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31038,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31039,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31040,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31041,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31042,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31043,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31044,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31045,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31046,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31047,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31048,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31049,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31050,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 26.45,,CLAIM ADJUSTMENT 3, 189.29,OTHER, 26.45, 367.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31051,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 14.46,,CLAIM ADJUSTMENT 3, 115.17,OTHER, 14.46, 224.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31052,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.41,,CLAIM ADJUSTMENT 3, 91.70,OTHER, 17.41, 220.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31053,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.41,,CLAIM ADJUSTMENT 3, 91.70,OTHER, 17.41, 220.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31054,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.07,,CLAIM ADJUSTMENT 3, 48.91,OTHER, 16.07, 90.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31055,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 10.51,,CLAIM ADJUSTMENT 3, 45.23,OTHER, 10.51, 85.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31056,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 17.08,OTHER, 7.46, 30.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31057,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 17.08,OTHER, 7.46, 30.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31058,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.65,,CLAIM ADJUSTMENT 3, 59.25,OTHER, 18.65, 110.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31059,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 36.65,,CLAIM ADJUSTMENT 3, 93.98,OTHER, 36.65, 171.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31060,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 36.65,,CLAIM ADJUSTMENT 3, 137.37,OTHER, 36.65, 258.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31061,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 23.14,,CLAIM ADJUSTMENT 3, 78.46,OTHER, 23.14, 146.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31062,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.28,,CLAIM ADJUSTMENT 3, 67.64,OTHER, 17.28, 127.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31063,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.28,,CLAIM ADJUSTMENT 3, 67.64,OTHER, 17.28, 127.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31064,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 29.26,,CLAIM ADJUSTMENT 3, 77.69,OTHER, 29.26, 141.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31065,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.65,,CLAIM ADJUSTMENT 3, 63.19,OTHER, 18.65, 117.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31066,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.79,,CLAIM ADJUSTMENT 3, 65.88,OTHER, 19.79, 127.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31067,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.79,,CLAIM ADJUSTMENT 3, 65.88,OTHER, 19.79, 127.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31068,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31069,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31070,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31071,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31072,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31073,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31074,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 68.02,OTHER, 17.35, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31075,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 68.02,OTHER, 17.35, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31076,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 68.02,OTHER, 17.35, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31077,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 120.82,OTHER, 17.35, 238.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31078,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 120.82,OTHER, 17.35, 238.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31079,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 14.46,,CLAIM ADJUSTMENT 3, 15.65,OTHER, 10.75, 24.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31080,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 80.94,OTHER, 29.96, 150.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31081,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 80.94,OTHER, 29.96, 150.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31082,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 85.12,OTHER, 29.96, 156.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31083,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 103.45,OTHER, 29.96, 193.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31084,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.97,,CLAIM ADJUSTMENT 3, 125.05,OTHER, 24.97, 345.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31085,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.97,,CLAIM ADJUSTMENT 3, 125.05,OTHER, 24.97, 345.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31086,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 50.54,OTHER, 7.46, 97.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31087,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 32.17,,CLAIM ADJUSTMENT 3, 88.87,OTHER, 32.17, 162.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31088,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 30.83,,CLAIM ADJUSTMENT 3, 66.43,OTHER, 30.83, 118.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31089,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 21.72,,CLAIM ADJUSTMENT 3, 57.43,OTHER, 21.72, 104.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31090,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 33.95,,CLAIM ADJUSTMENT 3, 265.06,OTHER, 33.95, 515.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31091,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 80.97,OTHER, 38.57, 144.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31092,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 80.97,OTHER, 38.57, 144.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31093,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 54.34,,CLAIM ADJUSTMENT 3, 111.82,OTHER, 54.34, 198.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31094,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 67.64,,CLAIM ADJUSTMENT 3, 176.22,OTHER, 67.64, 321.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31095,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 88.05,OTHER, 38.57, 158.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31096,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 88.05,OTHER, 38.57, 158.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31097,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.84,,CLAIM ADJUSTMENT 3, 68.73,OTHER, 13.84, 131.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31098,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.95,,CLAIM ADJUSTMENT 3, 96.09,OTHER, 20.95, 205.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31099,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.95,,CLAIM ADJUSTMENT 3, 96.09,OTHER, 20.95, 205.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31100,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.60,,CLAIM ADJUSTMENT 3, 70.10,OTHER, 19.60, 131.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31101,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 8.16,,CLAIM ADJUSTMENT 3, 46.86,OTHER, 8.16, 90.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31102,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 8.16,,CLAIM ADJUSTMENT 3, 46.86,OTHER, 8.16, 90.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31103,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 89.24,,CLAIM ADJUSTMENT 3, 191.67,OTHER, 89.24, 342.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31104,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.33,,CLAIM ADJUSTMENT 3, 12.31,OTHER, 8.04, 18.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31105,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.34,,CLAIM ADJUSTMENT 3, 18.56,OTHER, 6.34, 34.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31106,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 21.67,,CLAIM ADJUSTMENT 3, 36.21,OTHER, 21.67, 62.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31107,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 14.66,,CLAIM ADJUSTMENT 3, 55.25,OTHER, 14.66, 103.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31108,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.58,,CLAIM ADJUSTMENT 3, 40.13,OTHER, 18.58, 71.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31109,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.00,,CLAIM ADJUSTMENT 3, 66.54,OTHER, 19.00, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31110,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.53,,CLAIM ADJUSTMENT 3, 88.38,OTHER, 24.53, 165.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31111,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.53,,CLAIM ADJUSTMENT 3, 88.38,OTHER, 24.53, 165.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31112,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.53,,CLAIM ADJUSTMENT 3, 88.38,OTHER, 24.53, 165.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31113,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.29,,CLAIM ADJUSTMENT 3, 26.75,OTHER, 17.29, 45.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31114,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.51,,CLAIM ADJUSTMENT 3, 91.08,OTHER, 16.51, 254.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31115,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.51,,CLAIM ADJUSTMENT 3, 91.08,OTHER, 16.51, 254.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31116,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 50.83,OTHER, 20.72, 92.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31117,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 59.00,OTHER, 24.26, 106.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31118,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 22.02,,CLAIM ADJUSTMENT 3, 64.46,OTHER, 22.02, 118.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31119,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 26.12,,CLAIM ADJUSTMENT 3, 59.50,OTHER, 26.12, 106.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31120,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 26.12,,CLAIM ADJUSTMENT 3, 59.50,OTHER, 26.12, 106.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31121,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 71.41,OTHER, 24.26, 179.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31122,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 71.41,OTHER, 24.26, 179.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31123,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 71.41,OTHER, 24.26, 179.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31124,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 27.86,,CLAIM ADJUSTMENT 3, 66.70,OTHER, 27.86, 120.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31125,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 27.86,,CLAIM ADJUSTMENT 3, 66.70,OTHER, 27.86, 120.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31126,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 43.51,OTHER, 20.72, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31127,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.00,,CLAIM ADJUSTMENT 3, 47.68,OTHER, 19.00, 86.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31128,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 27.86,,CLAIM ADJUSTMENT 3, 58.39,OTHER, 27.86, 103.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31129,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.86,,CLAIM ADJUSTMENT 3, 77.47,OTHER, 19.86, 145.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31130,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.74,,CLAIM ADJUSTMENT 3, 62.50,OTHER, 19.74, 116.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31131,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 46.75,OTHER, 17.35, 85.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31132,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.94,,CLAIM ADJUSTMENT 3, 41.14,OTHER, 16.94, 74.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31133,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 67.08,OTHER, 15.47, 127.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31134,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.84,,CLAIM ADJUSTMENT 3, 50.52,OTHER, 17.84, 92.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31135,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.21,,CLAIM ADJUSTMENT 3, 28.18,OTHER, 16.21, 48.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31136,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.79,,CLAIM ADJUSTMENT 3, 52.54,OTHER, 18.79, 96.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31137,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.79,,CLAIM ADJUSTMENT 3, 52.54,OTHER, 18.79, 96.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31138,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.07,,CLAIM ADJUSTMENT 3, 41.16,OTHER, 19.07, 73.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31139,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 46.11,OTHER, 20.72, 82.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31140,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 46.11,OTHER, 20.72, 82.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31141,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 46.11,OTHER, 20.72, 82.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31142,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 48.00,OTHER, 18.55, 88.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31143,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 48.00,OTHER, 18.55, 88.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31144,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 48.00,OTHER, 18.55, 88.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31145,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.07,,CLAIM ADJUSTMENT 3, 49.38,OTHER, 19.07, 89.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31146,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 80.11,OTHER, 18.55, 151.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31147,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 80.11,OTHER, 18.55, 151.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31148,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 361.76,OTHER, 18.55, 717.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31149,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 20.54,,CLAIM ADJUSTMENT 3, 161.64,OTHER, 20.54, 314.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31150,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 92.44,,CLAIM ADJUSTMENT 3, 158.63,OTHER, 92.44, 274.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31151,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 92.44,,CLAIM ADJUSTMENT 3, 158.63,OTHER, 92.44, 274.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31152,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 14.06,,CLAIM ADJUSTMENT 3, 78.01,OTHER, 14.06, 149.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31153,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 14.06,,CLAIM ADJUSTMENT 3, 78.01,OTHER, 14.06, 149.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31154,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 14.06,,CLAIM ADJUSTMENT 3, 78.01,OTHER, 14.06, 149.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31155,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 152.44,OTHER, 102.77, 234.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31156,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 251.30,,CLAIM ADJUSTMENT 3, 270.23,OTHER, 185.27, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31157,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 251.30,,CLAIM ADJUSTMENT 3, 270.23,OTHER, 185.27, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31158,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 251.30,,CLAIM ADJUSTMENT 3, 270.23,OTHER, 185.27, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31159,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31160,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31161,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31162,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31163,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31164,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 146.86,OTHER, 7.46, 291.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31165,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 54.74,OTHER, 4.31, 107.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31166,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 54.74,OTHER, 4.31, 107.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31167,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 54.74,OTHER, 4.31, 107.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31168,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 44.77,OTHER, 4.31, 89.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31169,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 44.77,OTHER, 4.31, 89.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31170,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 44.77,OTHER, 4.31, 89.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31171,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.52,,CLAIM ADJUSTMENT 3, 205.30,OTHER, 5.52, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31172,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.52,,CLAIM ADJUSTMENT 3, 205.30,OTHER, 5.52, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31173,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.52,,CLAIM ADJUSTMENT 3, 205.30,OTHER, 5.52, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31174,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.16,,CLAIM ADJUSTMENT 3, 70.78,OTHER, 11.16, 136.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31175,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.16,,CLAIM ADJUSTMENT 3, 70.78,OTHER, 11.16, 136.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31176,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31177,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31178,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31179,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31180,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31181,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31182,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 35.20,,CLAIM ADJUSTMENT 3, 76.50,OTHER, 35.20, 136.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31183,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 91.25,,CLAIM ADJUSTMENT 3, 149.18,OTHER, 91.25, 255.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31184,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 14.86,,CLAIM ADJUSTMENT 3, 81.41,OTHER, 14.86, 156.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31185,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 14.86,,CLAIM ADJUSTMENT 3, 81.41,OTHER, 14.86, 156.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31186,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.60,,CLAIM ADJUSTMENT 3, 30.76,OTHER, 13.60, 55.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31187,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.41,,CLAIM ADJUSTMENT 3, 72.64,OTHER, 12.41, 139.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31188,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.41,,CLAIM ADJUSTMENT 3, 72.64,OTHER, 12.41, 139.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31189,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.63,,CLAIM ADJUSTMENT 3, 78.26,OTHER, 13.63, 150.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31190,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 13.63,,CLAIM ADJUSTMENT 3, 78.26,OTHER, 13.63, 150.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31191,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 78.99,OTHER, 11.64, 152.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31192,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 46.77,OTHER, 11.64, 88.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31193,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 46.77,OTHER, 11.64, 88.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31194,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 46.77,OTHER, 11.64, 88.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31195,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 9.55,,CLAIM ADJUSTMENT 3, 40.96,OTHER, 9.55, 77.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31196,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.62,,CLAIM ADJUSTMENT 3, 44.68,OTHER, 11.62, 84.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31197,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.62,,CLAIM ADJUSTMENT 3, 44.68,OTHER, 11.62, 84.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31198,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.62,,CLAIM ADJUSTMENT 3, 44.68,OTHER, 11.62, 84.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31199,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.65,,CLAIM ADJUSTMENT 3, 82.26,OTHER, 11.65, 159.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31200,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 11.65,,CLAIM ADJUSTMENT 3, 82.26,OTHER, 11.65, 159.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31201,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.11,,CLAIM ADJUSTMENT 3, 74.74,OTHER, 12.11, 144.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31202,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 15.55,,CLAIM ADJUSTMENT 3, 91.00,OTHER, 15.55, 175.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31203,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.82,,CLAIM ADJUSTMENT 3, 68.31,OTHER, 12.82, 130.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31204,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 17.74,OTHER, 6.84, 32.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31205,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 10.78,,CLAIM ADJUSTMENT 3, 22.99,OTHER, 10.78, 40.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31206,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 29.95,OTHER, 6.84, 56.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31207,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 12.46,,CLAIM ADJUSTMENT 3, 42.41,OTHER, 12.46, 79.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31208,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31209,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31210,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31211,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31212,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31213,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 38.14,OTHER, 7.76, 72.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31214,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 38.14,OTHER, 7.76, 72.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31215,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 8.38,,CLAIM ADJUSTMENT 3, 28.29,OTHER, 8.38, 52.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31216,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 28.16,,CLAIM ADJUSTMENT 3, 68.72,OTHER, 28.16, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31217,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.26,,CLAIM ADJUSTMENT 3, 299.39,OTHER, 17.26, 592.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31218,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 14.88,,CLAIM ADJUSTMENT 3, 40.67,OTHER, 14.88, 74.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31219,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 43.08,OTHER, 16.61, 78.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31220,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 121.25,OTHER, 19.08, 234.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31221,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 28.87,,CLAIM ADJUSTMENT 3, 68.89,OTHER, 28.87, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31222,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 106.28,OTHER, 50.53, 189.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31223,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 106.28,OTHER, 50.53, 189.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31224,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 53.66,,CLAIM ADJUSTMENT 3, 107.02,OTHER, 53.66, 189.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31225,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 53.66,,CLAIM ADJUSTMENT 3, 107.02,OTHER, 53.66, 189.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31226,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 53.66,,CLAIM ADJUSTMENT 3, 107.02,OTHER, 53.66, 189.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31227,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 198.86,OTHER, 61.69, 369.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31228,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 198.86,OTHER, 61.69, 369.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31229,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31230,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 221.47,OTHER, 61.69, 415.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31231,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 76.43,OTHER, 50.53, 129.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31232,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 122.54,,CLAIM ADJUSTMENT 3, 265.03,OTHER, 122.54, 473.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31233,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 106.28,OTHER, 50.53, 189.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31234,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31235,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31236,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 600.16,,CLAIM ADJUSTMENT 3, 445.68,OTHER, 266.63, 607.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31237,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31238,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31239,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31240,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 193.99,OTHER, 50.53, 365.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31241,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 193.99,OTHER, 50.53, 365.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31242,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31243,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 173.66,OTHER, 50.53, 324.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31244,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 28.87,,CLAIM ADJUSTMENT 3, 68.89,OTHER, 28.87, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31245,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 204.22,OTHER, 50.53, 599.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31246,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 204.22,OTHER, 50.53, 599.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31247,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 146.52,OTHER, 61.69, 264.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31248,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 146.52,OTHER, 61.69, 264.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31249,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 23.83,,CLAIM ADJUSTMENT 3, 62.25,OTHER, 23.83, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31250,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 23.83,,CLAIM ADJUSTMENT 3, 62.25,OTHER, 23.83, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31251,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.86,,CLAIM ADJUSTMENT 3, 43.07,OTHER, 18.86, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31252,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.86,,CLAIM ADJUSTMENT 3, 43.07,OTHER, 18.86, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31253,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 23.81,,CLAIM ADJUSTMENT 3, 44.25,OTHER, 23.81, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31254,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 23.81,,CLAIM ADJUSTMENT 3, 17.88,OTHER, 10.75, 24.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31255,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 23.14,,CLAIM ADJUSTMENT 3, 100.14,OTHER, 23.14, 189.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31256,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 370.73,,CLAIM ADJUSTMENT 3, 800.72,OTHER, 370.73, 1429.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31257,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 370.73,,CLAIM ADJUSTMENT 3, 800.72,OTHER, 370.73, 1429.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31258,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 38.32,,CLAIM ADJUSTMENT 3, 59.91,OTHER, 38.32, 101.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31259,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 38.32,,CLAIM ADJUSTMENT 3, 59.91,OTHER, 38.32, 101.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31260,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 97.97,,CLAIM ADJUSTMENT 3, 294.34,OTHER, 97.97, 543.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31261,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31262,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31263,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.79,,CLAIM ADJUSTMENT 3, 16.75,OTHER, 6.79, 30.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31264,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 6.79,,CLAIM ADJUSTMENT 3, 16.75,OTHER, 6.79, 30.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31265,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 8.06,,CLAIM ADJUSTMENT 3, 56.81,OTHER, 8.06, 110.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31266,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 10.56,,CLAIM ADJUSTMENT 3, 39.98,OTHER, 10.56, 75.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31267,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 41.73,OTHER, 17.35, 75.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31268,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31269,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 63.90,OTHER, 37.34, 110.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31270,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 63.90,OTHER, 37.34, 110.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31271,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 23.30,OTHER, 12.69, 37.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31272,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 37.95,OTHER, 25.59, 58.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31273,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 23.42,OTHER, 12.79, 37.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31274,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31275,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31276,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 315.54,,CLAIM ADJUSTMENT 3, 149.84,OTHER, 65.79, 315.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31277,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 315.54,,CLAIM ADJUSTMENT 3, 149.84,OTHER, 65.79, 315.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31278,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31279,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 71.34,,CLAIM ADJUSTMENT 3, 41.40,OTHER, 21.50, 71.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31280,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 71.34,,CLAIM ADJUSTMENT 3, 41.40,OTHER, 21.50, 71.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31281,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 280.30,,CLAIM ADJUSTMENT 3, 356.50,OTHER, 255.16, 581.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31282,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 345.38,,CLAIM ADJUSTMENT 3, 687.64,OTHER, 345.38, 1214.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31283,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31284,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31285,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31286,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 77.65,,CLAIM ADJUSTMENT 3, 60.00,OTHER, 36.55, 83.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31287,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 48.79,,CLAIM ADJUSTMENT 3, 36.74,OTHER, 22.12, 50.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31288,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 48.79,,CLAIM ADJUSTMENT 3, 36.74,OTHER, 22.12, 50.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31289,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31290,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31291,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31292,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31293,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31294,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31295,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31296,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31297,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31298,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31299,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31300,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 143.83,,CLAIM ADJUSTMENT 3, 111.30,OTHER, 67.85, 154.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31301,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 143.83,,CLAIM ADJUSTMENT 3, 111.30,OTHER, 67.85, 154.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31302,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31303,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31304,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 89.44,,CLAIM ADJUSTMENT 3, 104.75,OTHER, 73.49, 167.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31305,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 89.44,,CLAIM ADJUSTMENT 3, 104.75,OTHER, 73.49, 167.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31306,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 33.16,,CLAIM ADJUSTMENT 3, 12.78,OTHER, 4.30, 33.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31307,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 5.09,,CLAIM ADJUSTMENT 3, 17.36,OTHER, 5.09, 32.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31308,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 184.48,OTHER, 130.68, 297.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31309,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 202.35,OTHER, 146.42, 333.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31310,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 113.95,,CLAIM ADJUSTMENT 3, 99.37,OTHER, 63.61, 144.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31311,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 59.56,,CLAIM ADJUSTMENT 3, 88.44,OTHER, 59.56, 149.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31312,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 131.72,OTHER, 84.22, 191.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31313,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 96.67,,CLAIM ADJUSTMENT 3, 117.05,OTHER, 82.81, 188.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31314,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 179.75,OTHER, 126.51, 288.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31315,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 143.72,,CLAIM ADJUSTMENT 3, 158.52,OTHER, 109.46, 249.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31316,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 186.21,OTHER, 132.20, 301.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31317,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 50.93,,CLAIM ADJUSTMENT 3, 83.96,OTHER, 50.93, 144.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31318,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 216.78,,CLAIM ADJUSTMENT 3, 167.44,OTHER, 102.00, 232.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31319,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 216.78,,CLAIM ADJUSTMENT 3, 172.28,OTHER, 106.26, 242.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31320,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 87.35,,CLAIM ADJUSTMENT 3, 49.86,OTHER, 25.59, 87.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31321,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 85.51,,CLAIM ADJUSTMENT 3, 141.43,OTHER, 85.51, 242.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31322,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 69.71,OTHER, 45.42, 103.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31323,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 177.65,OTHER, 120.47, 274.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31324,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 189.46,OTHER, 130.87, 298.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31325,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 279.93,OTHER, 171.54, 479.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31326,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 265.00,OTHER, 171.54, 449.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31327,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 113.59,,CLAIM ADJUSTMENT 3, 149.90,OTHER, 108.18, 246.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31328,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 46.09,,CLAIM ADJUSTMENT 3, 167.02,OTHER, 46.09, 313.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31329,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 46.09,,CLAIM ADJUSTMENT 3, 76.10,OTHER, 46.09, 130.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31330,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 46.09,,CLAIM ADJUSTMENT 3, 147.35,OTHER, 46.09, 273.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31331,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 227.22,OTHER, 124.32, 396.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31332,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 295.49,OTHER, 124.32, 533.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31333,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 114.40,OTHER, 74.67, 170.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31334,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 155.48,OTHER, 110.85, 252.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31335,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31336,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31337,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31338,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 114.13,,CLAIM ADJUSTMENT 3, 36.72,OTHER, 8.41, 114.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31339,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 114.13,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 114.13, 360.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31340,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 114.13,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 114.13, 360.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31341,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 346.21,,CLAIM ADJUSTMENT 3, 526.62,OTHER, 346.21, 891.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31342,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 346.21,,CLAIM ADJUSTMENT 3, 290.83,OTHER, 143.52, 346.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31343,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31344,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 49.24,,CLAIM ADJUSTMENT 3, 162.12,OTHER, 49.24, 301.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31345,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 80.99,,CLAIM ADJUSTMENT 3, 140.39,OTHER, 80.99, 243.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31346,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 80.99,,CLAIM ADJUSTMENT 3, 140.39,OTHER, 80.99, 243.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31347,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 51.13,,CLAIM ADJUSTMENT 3, 166.97,OTHER, 51.13, 310.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31348,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 51.13,,CLAIM ADJUSTMENT 3, 54.96,OTHER, 37.67, 85.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31349,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 51.13,,CLAIM ADJUSTMENT 3, 86.43,OTHER, 51.13, 149.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31350,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 656.16,,CLAIM ADJUSTMENT 3, 950.56,OTHER, 656.16, 1594.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31351,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 656.16,,CLAIM ADJUSTMENT 3, 375.80,OTHER, 121.44, 656.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31352,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 545.72,OTHER, 384.68, 911.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31353,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 545.72,OTHER, 384.68, 911.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31354,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 278.85,OTHER, 121.44, 384.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31355,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 278.85,OTHER, 121.44, 384.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31356,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 591.97,OTHER, 225.62, 1080.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31357,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31358,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 96.59,,CLAIM ADJUSTMENT 3, 250.40,OTHER, 96.59, 456.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31359,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 96.59,,CLAIM ADJUSTMENT 3, 250.40,OTHER, 96.59, 456.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31360,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 157.67,,CLAIM ADJUSTMENT 3, 197.77,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31361,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 563.65,OTHER, 225.62, 1023.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31362,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31363,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 113.30,OTHER, 70.09, 159.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31364,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 113.30,OTHER, 70.09, 159.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31365,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31366,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31367,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 297.88,OTHER, 215.00, 490.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31368,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31369,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 262.11,OTHER, 141.55, 458.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31370,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 262.11,OTHER, 141.55, 458.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31371,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31372,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31373,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 673.61,OTHER, 225.62, 1244.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31374,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 673.61,OTHER, 225.62, 1244.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31375,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 383.08,OTHER, 225.62, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31376,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 673.61,OTHER, 225.62, 1244.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31377,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31378,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31379,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31380,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31381,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31382,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31383,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31384,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31385,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31386,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31387,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31388,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31389,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 655.39,OTHER, 225.62, 1207.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31390,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31391,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 284.89,,CLAIM ADJUSTMENT 3, 1042.14,OTHER, 284.89, 2539.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31392,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 284.89,,CLAIM ADJUSTMENT 3, 1042.14,OTHER, 284.89, 2539.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31393,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 184.77,OTHER, 39.56, 427.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31394,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 184.77,OTHER, 39.56, 427.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31395,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 138.71,,CLAIM ADJUSTMENT 3, 547.41,OTHER, 138.71, 1032.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31396,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 152.82,,CLAIM ADJUSTMENT 3, 154.36,OTHER, 103.88, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31397,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 152.82,,CLAIM ADJUSTMENT 3, 154.36,OTHER, 103.88, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31398,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 199.86,OTHER, 125.79, 286.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31399,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 199.86,OTHER, 125.79, 286.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31400,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 407.38,OTHER, 140.42, 864.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31401,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 407.38,OTHER, 140.42, 864.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31402,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 407.38,OTHER, 140.42, 864.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31403,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 332.46,OTHER, 140.42, 600.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31404,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 239.03,OTHER, 160.29, 365.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31405,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 239.03,OTHER, 160.29, 365.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31406,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 174.98,OTHER, 103.88, 239.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31407,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 136.10,OTHER, 76.16, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31408,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 140.33,OTHER, 74.39, 234.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31409,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 87.35,,CLAIM ADJUSTMENT 3, 228.33,OTHER, 87.35, 416.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31410,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31411,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31412,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 94.34,,CLAIM ADJUSTMENT 3, 182.46,OTHER, 94.34, 321.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31413,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 94.34,,CLAIM ADJUSTMENT 3, 182.46,OTHER, 94.34, 321.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31414,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 125.89,OTHER, 61.67, 234.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31415,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 125.89,OTHER, 61.67, 234.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31416,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 235.80,,CLAIM ADJUSTMENT 3, 415.63,OTHER, 235.80, 721.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31417,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 1853.96,OTHER, 1121.15, 3185.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31418,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 1853.96,OTHER, 1121.15, 3185.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31419,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 2171.37,OTHER, 1121.15, 3822.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31420,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 2171.37,OTHER, 1121.15, 3822.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31421,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 2171.37,OTHER, 1121.15, 3822.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31422,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 85.61,,CLAIM ADJUSTMENT 3, 152.82,OTHER, 85.61, 265.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31423,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 89.47,,CLAIM ADJUSTMENT 3, 165.98,OTHER, 89.47, 290.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31424,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 110.12,,CLAIM ADJUSTMENT 3, 260.74,OTHER, 110.12, 470.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31425,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 110.12,,CLAIM ADJUSTMENT 3, 260.74,OTHER, 110.12, 470.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31426,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 96.89,OTHER, 37.34, 176.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31427,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 96.89,OTHER, 37.34, 176.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31428,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 184.46,,CLAIM ADJUSTMENT 3, 323.07,OTHER, 184.46, 560.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31429,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 184.46,,CLAIM ADJUSTMENT 3, 323.07,OTHER, 184.46, 560.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31430,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 184.46,,CLAIM ADJUSTMENT 3, 323.07,OTHER, 184.46, 560.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31431,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 89.33,OTHER, 37.34, 161.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31432,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 89.33,OTHER, 37.34, 161.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31433,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 108.89,OTHER, 54.48, 192.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31434,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 108.89,OTHER, 54.48, 192.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31435,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31436,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31437,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 84.04,OTHER, 37.34, 150.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31438,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 84.04,OTHER, 37.34, 150.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31439,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 37.95,OTHER, 25.59, 58.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31440,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 37.95,OTHER, 25.59, 58.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31441,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 159.88,OTHER, 54.48, 294.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31442,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 159.88,OTHER, 54.48, 294.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31443,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 96.44,OTHER, 54.48, 167.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31444,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 96.44,OTHER, 54.48, 167.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31445,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31446,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31447,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 21.01,,CLAIM ADJUSTMENT 3, 47.95,OTHER, 21.01, 86.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31448,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 21.01,,CLAIM ADJUSTMENT 3, 47.95,OTHER, 21.01, 86.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31449,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 34.39,,CLAIM ADJUSTMENT 3, 55.33,OTHER, 34.39, 94.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31450,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 34.39,,CLAIM ADJUSTMENT 3, 55.33,OTHER, 34.39, 94.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31451,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 29.74,,CLAIM ADJUSTMENT 3, 58.74,OTHER, 29.74, 103.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31452,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 29.74,,CLAIM ADJUSTMENT 3, 58.74,OTHER, 29.74, 103.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31453,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 29.74,,CLAIM ADJUSTMENT 3, 58.74,OTHER, 29.74, 103.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31454,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 28.82,,CLAIM ADJUSTMENT 3, 142.33,OTHER, 28.82, 411.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31455,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 28.82,,CLAIM ADJUSTMENT 3, 142.33,OTHER, 28.82, 411.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31456,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 28.82,,CLAIM ADJUSTMENT 3, 72.71,OTHER, 28.82, 132.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31457,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 74.33,OTHER, 52.80, 120.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31458,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 74.33,OTHER, 52.80, 120.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31459,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 74.35,OTHER, 52.84, 120.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31460,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 69.01,,CLAIM ADJUSTMENT 3, 80.43,OTHER, 56.36, 128.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31461,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 69.01,,CLAIM ADJUSTMENT 3, 80.43,OTHER, 56.36, 128.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31462,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 69.01,,CLAIM ADJUSTMENT 3, 80.43,OTHER, 56.36, 128.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31463,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 60.80,OTHER, 40.91, 93.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31464,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 60.80,OTHER, 40.91, 93.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31465,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 61.55,,CLAIM ADJUSTMENT 3, 47.68,OTHER, 29.08, 66.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31466,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 46.96,,CLAIM ADJUSTMENT 3, 98.59,OTHER, 46.96, 175.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31467,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 46.96,,CLAIM ADJUSTMENT 3, 98.59,OTHER, 46.96, 175.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31468,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 46.96,,CLAIM ADJUSTMENT 3, 98.59,OTHER, 46.96, 175.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31469,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 44.87,,CLAIM ADJUSTMENT 3, 115.67,OTHER, 44.87, 210.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31470,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 44.87,,CLAIM ADJUSTMENT 3, 115.67,OTHER, 44.87, 210.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31471,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 44.87,,CLAIM ADJUSTMENT 3, 115.67,OTHER, 44.87, 210.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31472,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 55.58,,CLAIM ADJUSTMENT 3, 73.14,OTHER, 52.75, 120.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31473,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 55.58,,CLAIM ADJUSTMENT 3, 73.14,OTHER, 52.75, 120.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31474,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 55.58,,CLAIM ADJUSTMENT 3, 73.14,OTHER, 52.75, 120.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31475,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.13,,CLAIM ADJUSTMENT 3, 30.33,OTHER, 18.92, 43.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31476,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 206.21,,CLAIM ADJUSTMENT 3, 178.52,OTHER, 113.97, 259.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31477,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 206.21,,CLAIM ADJUSTMENT 3, 202.67,OTHER, 135.24, 308.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31478,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 206.21,,CLAIM ADJUSTMENT 3, 194.50,OTHER, 128.04, 291.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31479,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 142.50,,CLAIM ADJUSTMENT 3, 106.37,OTHER, 63.79, 145.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31480,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 208.14,,CLAIM ADJUSTMENT 3, 173.75,OTHER, 109.36, 249.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31481,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 208.14,,CLAIM ADJUSTMENT 3, 180.83,OTHER, 115.60, 263.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31482,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 208.14,,CLAIM ADJUSTMENT 3, 204.49,OTHER, 136.43, 310.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31483,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 143.15,,CLAIM ADJUSTMENT 3, 108.91,OTHER, 65.89, 150.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31484,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 41.16,,CLAIM ADJUSTMENT 3, 68.75,OTHER, 41.16, 118.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31485,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 41.16,,CLAIM ADJUSTMENT 3, 68.75,OTHER, 41.16, 118.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31486,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 41.16,,CLAIM ADJUSTMENT 3, 68.75,OTHER, 41.16, 118.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31487,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 44.69,OTHER, 31.56, 71.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31488,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 66.74,,CLAIM ADJUSTMENT 3, 78.22,OTHER, 54.89, 125.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31489,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 66.74,,CLAIM ADJUSTMENT 3, 78.22,OTHER, 54.89, 125.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31490,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 66.74,,CLAIM ADJUSTMENT 3, 59.17,OTHER, 38.11, 86.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31491,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 39.73,,CLAIM ADJUSTMENT 3, 66.10,OTHER, 39.73, 113.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31492,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 39.73,,CLAIM ADJUSTMENT 3, 66.10,OTHER, 39.73, 113.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31493,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 39.73,,CLAIM ADJUSTMENT 3, 66.10,OTHER, 39.73, 113.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31494,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 68.90,OTHER, 12.81, 151.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31495,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 96.26,,CLAIM ADJUSTMENT 3, 93.12,OTHER, 61.82, 140.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31496,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 84.59,,CLAIM ADJUSTMENT 3, 114.40,OTHER, 52.03, 259.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31497,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 84.59,,CLAIM ADJUSTMENT 3, 114.40,OTHER, 52.03, 259.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31498,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 105.23,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 53.32, 121.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31499,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 105.23,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 53.32, 121.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31500,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 105.23,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 53.32, 121.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31501,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31502,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31503,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31504,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31505,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31506,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31507,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31508,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31509,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31510,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31511,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 114.64,,CLAIM ADJUSTMENT 3, 145.27,OTHER, 103.88, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31512,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31513,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31514,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31515,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31516,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31517,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31518,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31519,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31520,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31521,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31522,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31523,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31524,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31525,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31526,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31527,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31528,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31529,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31530,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31531,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 103.66,,CLAIM ADJUSTMENT 3, 111.61,OTHER, 64.03, 142.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31532,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 164.56,,CLAIM ADJUSTMENT 3, 149.82,OTHER, 78.16, 173.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31533,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 247.58,,CLAIM ADJUSTMENT 3, 220.11,OTHER, 113.05, 250.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31534,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 149.74,OTHER, 77.35, 263.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31535,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 149.74,OTHER, 77.35, 263.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31536,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 156.74,OTHER, 77.35, 245.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31537,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 156.74,OTHER, 77.35, 245.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31538,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 233.57,OTHER, 127.82, 407.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31539,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 233.57,OTHER, 127.82, 407.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31540,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 197.91,OTHER, 127.82, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31541,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 197.91,OTHER, 127.82, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31542,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 369.55,OTHER, 203.96, 644.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31543,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 369.55,OTHER, 203.96, 644.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31544,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 247.74,OTHER, 150.14, 333.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31545,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 247.74,OTHER, 150.14, 333.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31546,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 580.80,OTHER, 324.71, 1010.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31547,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 580.80,OTHER, 324.71, 1010.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31548,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 332.53,OTHER, 185.91, 412.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31549,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 332.53,OTHER, 185.91, 412.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31550,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 479.76,,CLAIM ADJUSTMENT 3, 954.02,OTHER, 479.76, 1685.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31551,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 479.76,,CLAIM ADJUSTMENT 3, 954.02,OTHER, 479.76, 1685.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31552,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 479.76,,CLAIM ADJUSTMENT 3, 429.06,OTHER, 221.24, 490.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31553,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 720.78,,CLAIM ADJUSTMENT 3, 1514.86,OTHER, 720.78, 2695.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31554,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31555,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31556,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31557,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31558,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 167.97,OTHER, 113.31, 258.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31559,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 173.37,OTHER, 118.06, 269.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31560,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 179.18,OTHER, 123.17, 280.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31561,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 197.44,OTHER, 139.26, 317.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31562,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 192.88,OTHER, 135.24, 308.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31563,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31564,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31565,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 155.10,OTHER, 101.97, 232.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31566,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 162.99,OTHER, 108.92, 248.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31567,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 174.20,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31568,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 174.20,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31569,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 174.20,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31570,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 177.10,OTHER, 121.35, 276.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31571,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31572,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31573,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31574,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31575,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31576,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31577,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 30.74,,CLAIM ADJUSTMENT 3, 33.14,OTHER, 22.74, 51.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31578,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 30.74,,CLAIM ADJUSTMENT 3, 39.28,OTHER, 28.14, 64.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31579,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31580,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31581,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31582,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31583,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 101.33,,CLAIM ADJUSTMENT 3, 148.65,OTHER, 101.33, 249.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31584,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 133.36,,CLAIM ADJUSTMENT 3, 166.04,OTHER, 118.25, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31585,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31586,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31587,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 680.93,,CLAIM ADJUSTMENT 3, 350.13,OTHER, 165.55, 680.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31588,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 680.93,,CLAIM ADJUSTMENT 3, 350.13,OTHER, 165.55, 680.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31589,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1078.14,,CLAIM ADJUSTMENT 3, 553.11,OTHER, 261.01, 1078.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31590,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1078.14,,CLAIM ADJUSTMENT 3, 553.11,OTHER, 261.01, 1078.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31591,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 567.43,,CLAIM ADJUSTMENT 3, 308.45,OTHER, 152.65, 567.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31592,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 567.43,,CLAIM ADJUSTMENT 3, 308.45,OTHER, 152.65, 567.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31593,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 907.91,,CLAIM ADJUSTMENT 3, 466.19,OTHER, 220.16, 907.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31594,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 907.91,,CLAIM ADJUSTMENT 3, 466.19,OTHER, 220.16, 907.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31595,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31596,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31597,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31598,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31599,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31600,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31601,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31602,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1648.47,OTHER, 779.04, 2936.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31603,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1648.47,OTHER, 779.04, 2936.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31604,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1777.88,OTHER, 779.04, 3195.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31605,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1777.88,OTHER, 779.04, 3195.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31606,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1244.21,OTHER, 508.57, 2254.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31607,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1244.21,OTHER, 508.57, 2254.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31608,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1244.21,OTHER, 508.57, 2254.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31609,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1097.72,OTHER, 508.57, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31610,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1097.72,OTHER, 508.57, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31611,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1162.11,OTHER, 779.04, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31612,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1162.11,OTHER, 779.04, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31613,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1.66,,CLAIM ADJUSTMENT 3, 9.74,OTHER, 1.66, 18.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31614,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 63.90,OTHER, 37.34, 110.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31615,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 11.82,OTHER, 2.58, 37.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31616,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31617,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31618,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 33.71,,CLAIM ADJUSTMENT 3, 88.75,OTHER, 33.71, 162.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31619,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 33.71,,CLAIM ADJUSTMENT 3, 58.81,OTHER, 33.71, 101.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31620,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31621,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 231.89,OTHER, 165.06, 386.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31622,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 231.89,OTHER, 165.06, 386.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31623,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 35.44,OTHER, 18.28, 61.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31624,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 44.57,OTHER, 26.32, 61.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31625,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31626,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31627,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31628,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31629,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31630,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31631,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31632,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31633,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31634,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31635,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31636,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31637,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31638,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31639,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31640,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31641,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31642,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31643,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31644,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31645,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31646,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31647,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31648,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31649,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1597.44,,CLAIM ADJUSTMENT 3, 575.18,OTHER, 171.57, 1597.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31650,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2082.47,,CLAIM ADJUSTMENT 3, 690.66,OTHER, 171.57, 2082.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31651,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1937.50,,CLAIM ADJUSTMENT 3, 656.15,OTHER, 171.57, 1937.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31652,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 1734.01,,CLAIM ADJUSTMENT 3, 607.70,OTHER, 171.57, 1734.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31653,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 2065.06,,CLAIM ADJUSTMENT 3, 735.35,OTHER, 214.57, 2065.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31654,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 18.42,,CLAIM ADJUSTMENT 3, 421.89,OTHER, 18.42, 837.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31655,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31656,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31657,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31658,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31659,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31660,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31661,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31662,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31663,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31664,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31665,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31666,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31667,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31668,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31669,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31670,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31671,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31672,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31673,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31674,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31675,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31676,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31677,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31678,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31679,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31680,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31681,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31682,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31683,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31684,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31685,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31686,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31687,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31688,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31689,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31690,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31691,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31692,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 42.53,,CLAIM ADJUSTMENT 3, 62.01,OTHER, 42.53, 104.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31693,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31694,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31695,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31696,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31697,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31698,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31699,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31700,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31701,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31702,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31703,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31704,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31705,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31706,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31707,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31708,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31709,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31710,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31711,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31712,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31713,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31714,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31715,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31716,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31717,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31718,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31719,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31720,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31721,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31722,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31723,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31724,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31725,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31726,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31727,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31728,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31729,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31730,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31731,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31732,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31733,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31734,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31735,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31736,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31737,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31738,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31739,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31740,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31741,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31742,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31743,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31744,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31745,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31746,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31747,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31748,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31749,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31750,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31751,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31752,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31753,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31754,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31755,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31756,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31757,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31758,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31759,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31760,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31761,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31762,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31763,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31764,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31765,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31766,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31767,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31768,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31769,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31770,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31771,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31772,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31773,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31774,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31775,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31776,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31777,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31778,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31779,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31780,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31781,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31782,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31783,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31784,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31785,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31786,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31787,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31788,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31789,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31790,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31791,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31792,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31793,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31794,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31795,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31796,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31797,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31798,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31799,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31800,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31801,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31802,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31803,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31804,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31805,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31806,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31807,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31808,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31809,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31810,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31811,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31812,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31813,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31814,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31815,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31816,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31817,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31818,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31819,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31820,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31821,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31822,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31823,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31824,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 31825,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,PRESBY_TURQ_MEDICAID,PRESBYTERIAN TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 31826,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,SELFPAY,SELF PAY, 862.50,,OUTPCT LIMIT, 920.20,OTHER, 507.84, 1127.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31827,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,SELFPAY,SELF PAY, 637.50,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31828,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,SELFPAY,SELF PAY, 1031.25,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31829,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31830,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31831,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31832,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31833,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31834,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31835,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31836,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31837,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31838,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31839,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31840,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31841,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31842,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31843,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31844,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,SELFPAY,SELF PAY, 365.10,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31845,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,SELFPAY,SELF PAY, 365.10,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31846,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,SELFPAY,SELF PAY, 207.19,,OUTPCT LIMIT, 168.89,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31847,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,SELFPAY,SELF PAY, 175.50,,OUTPCT LIMIT, 171.36,OTHER, 103.33, 229.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31848,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,SELFPAY,SELF PAY, 368.42,,OUTPCT LIMIT, 273.87,OTHER, 142.76, 481.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31849,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,SELFPAY,SELF PAY, 329.25,,OUTPCT LIMIT, 276.81,OTHER, 142.76, 430.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31850,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,SELFPAY,SELF PAY, 271.58,,OUTPCT LIMIT, 242.16,OTHER, 155.70, 354.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31851,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,SELFPAY,SELF PAY, 345.75,,OUTPCT LIMIT, 850.02,OTHER, 203.58, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31852,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,SELFPAY,SELF PAY, 329.25,,OUTPCT LIMIT, 667.92,OTHER, 193.86, 1237.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31853,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,SELFPAY,SELF PAY, 115.50,,OUTPCT LIMIT, 177.23,OTHER, 68.01, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31854,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,SELFPAY,SELF PAY, 52.50,,OUTPCT LIMIT, 131.69,OTHER, 30.91, 267.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31855,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,SELFPAY,SELF PAY, 95.25,,OUTPCT LIMIT, 116.49,OTHER, 56.08, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31856,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,SELFPAY,SELF PAY, 457.50,,OUTPCT LIMIT, 405.48,OTHER, 256.74, 597.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31857,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,SELFPAY,SELF PAY, 275.25,,OUTPCT LIMIT, 293.67,OTHER, 162.07, 359.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31858,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,SELFPAY,SELF PAY, 182.25,,OUTPCT LIMIT, 216.69,OTHER, 107.31, 256.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31859,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,SELFPAY,SELF PAY, 57.75,,OUTPCT LIMIT, 61.61,OTHER, 34.00, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31860,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,SELFPAY,SELF PAY, 102.75,,OUTPCT LIMIT, 233.68,OTHER, 60.50, 456.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31861,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,SELFPAY,SELF PAY, 156.75,,OUTPCT LIMIT, 158.67,OTHER, 92.29, 204.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31862,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,SELFPAY,SELF PAY, 119.25,,OUTPCT LIMIT, 112.58,OTHER, 70.21, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31863,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,SELFPAY,SELF PAY, 138.00,,OUTPCT LIMIT, 125.44,OTHER, 81.25, 180.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31864,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,SELFPAY,SELF PAY, 87.75,,OUTPCT LIMIT, 114.17,OTHER, 51.67, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31865,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,SELFPAY,SELF PAY, 103.50,,OUTPCT LIMIT, 122.15,OTHER, 60.94, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31866,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,SELFPAY,SELF PAY, 157.50,,OUTPCT LIMIT, 138.81,OTHER, 86.20, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31867,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,SELFPAY,SELF PAY, 126.00,,OUTPCT LIMIT, 117.21,OTHER, 74.19, 164.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31868,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,SELFPAY,SELF PAY, 153.75,,OUTPCT LIMIT, 258.26,OTHER, 90.53, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31869,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,SELFPAY,SELF PAY, 196.50,,OUTPCT LIMIT, 287.58,OTHER, 115.70, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31870,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,SELFPAY,SELF PAY, 264.75,,OUTPCT LIMIT, 334.39,OTHER, 155.88, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31871,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,SELFPAY,SELF PAY, 1789.50,,OUTPCT LIMIT, 1514.68,OTHER, 804.50, 2338.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31872,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,SELFPAY,SELF PAY, 1011.00,,OUTPCT LIMIT, 1306.30,OTHER, 595.28, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31873,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,SELFPAY,SELF PAY, 456.00,,OUTPCT LIMIT, 925.64,OTHER, 268.49, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31874,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,SELFPAY,SELF PAY, 149.25,,OUTPCT LIMIT, 389.69,OTHER, 87.88, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31875,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,SELFPAY,SELF PAY, 204.00,,OUTPCT LIMIT, 427.24,OTHER, 120.12, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31876,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,SELFPAY,SELF PAY, 248.25,,OUTPCT LIMIT, 457.59,OTHER, 146.17, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31877,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,SELFPAY,SELF PAY, 174.75,,OUTPCT LIMIT, 732.74,OTHER, 102.89, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31878,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,SELFPAY,SELF PAY, 509.25,,OUTPCT LIMIT, 1168.49,OTHER, 299.85, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31879,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,SELFPAY,SELF PAY, 215.25,,OUTPCT LIMIT, 300.44,OTHER, 126.74, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31880,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,SELFPAY,SELF PAY, 303.00,,OUTPCT LIMIT, 495.14,OTHER, 178.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31881,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,SELFPAY,SELF PAY, 360.75,,OUTPCT LIMIT, 534.75,OTHER, 212.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31882,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,SELFPAY,SELF PAY, 416.25,,OUTPCT LIMIT, 572.81,OTHER, 245.09, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31883,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,SELFPAY,SELF PAY, 371.25,,OUTPCT LIMIT, 541.95,OTHER, 218.59, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31884,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,SELFPAY,SELF PAY, 425.25,,OUTPCT LIMIT, 578.99,OTHER, 250.39, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31885,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,SELFPAY,SELF PAY, 1302.00,,OUTPCT LIMIT, 1505.88,OTHER, 766.62, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31886,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,SELFPAY,SELF PAY, 524.25,,OUTPCT LIMIT, 646.89,OTHER, 308.68, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31887,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,SELFPAY,SELF PAY, 617.25,,OUTPCT LIMIT, 1242.56,OTHER, 363.44, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31888,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,SELFPAY,SELF PAY, 329.25,,OUTPCT LIMIT, 513.14,OTHER, 193.86, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31889,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,SELFPAY,SELF PAY, 340.50,,OUTPCT LIMIT, 520.86,OTHER, 200.49, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31890,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,SELFPAY,SELF PAY, 594.00,,OUTPCT LIMIT, 694.73,OTHER, 349.75, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31891,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,SELFPAY,SELF PAY, 488.25,,OUTPCT LIMIT, 947.76,OTHER, 287.48, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31892,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,SELFPAY,SELF PAY, 837.00,,OUTPCT LIMIT, 1393.28,OTHER, 492.83, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31893,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,SELFPAY,SELF PAY, 42.00,,OUTPCT LIMIT, 56.01,OTHER, 24.73, 76.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31894,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,SELFPAY,SELF PAY, 253.43,,OUTPCT LIMIT, 185.53,OTHER, 86.20, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31895,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,SELFPAY,SELF PAY, 96.96,,OUTPCT LIMIT, 97.29,OTHER, 57.09, 126.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31896,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,SELFPAY,SELF PAY, 96.75,,OUTPCT LIMIT, 97.14,OTHER, 56.97, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31897,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,SELFPAY,SELF PAY, 38.25,,OUTPCT LIMIT, 57.02,OTHER, 22.52, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31898,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,SELFPAY,SELF PAY, 321.00,,OUTPCT LIMIT, 372.97,OTHER, 189.00, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31899,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,SELFPAY,SELF PAY, 915.00,,OUTPCT LIMIT, 1446.78,OTHER, 538.75, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31900,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,SELFPAY,SELF PAY, 441.00,,OUTPCT LIMIT, 1121.68,OTHER, 259.66, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31901,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,SELFPAY,SELF PAY, 287.81,,OUTPCT LIMIT, 278.63,OTHER, 165.01, 383.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31902,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,SELFPAY,SELF PAY, 516.63,,OUTPCT LIMIT, 427.61,OTHER, 296.20, 675.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31903,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,SELFPAY,SELF PAY, 312.64,,OUTPCT LIMIT, 237.66,OTHER, 143.26, 408.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31904,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,SELFPAY,SELF PAY, 337.20,,OUTPCT LIMIT, 253.66,OTHER, 143.26, 440.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31905,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,SELFPAY,SELF PAY, 365.63,,OUTPCT LIMIT, 272.17,OTHER, 143.26, 477.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31906,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,SELFPAY,SELF PAY, 333.73,,OUTPCT LIMIT, 251.39,OTHER, 143.26, 436.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31907,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,SELFPAY,SELF PAY, 306.75,,OUTPCT LIMIT, 261.55,OTHER, 143.26, 400.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31908,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,SELFPAY,SELF PAY, 353.94,,OUTPCT LIMIT, 264.56,OTHER, 143.26, 462.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31909,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,SELFPAY,SELF PAY, 357.53,,OUTPCT LIMIT, 306.35,OTHER, 204.98, 467.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31910,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,SELFPAY,SELF PAY, 638.25,,OUTPCT LIMIT, 548.12,OTHER, 309.01, 833.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31911,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,SELFPAY,SELF PAY, 369.00,,OUTPCT LIMIT, 300.52,OTHER, 132.82, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31912,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,SELFPAY,SELF PAY, 401.57,,OUTPCT LIMIT, 293.08,OTHER, 132.82, 524.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31913,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,SELFPAY,SELF PAY, 1459.40,,OUTPCT LIMIT, 1023.77,OTHER, 309.01, 1906.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31914,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,SELFPAY,SELF PAY, 565.50,,OUTPCT LIMIT, 498.22,OTHER, 309.01, 738.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31915,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,SELFPAY,SELF PAY, 2457.20,,OUTPCT LIMIT, 1703.49,OTHER, 435.32, 3210.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31916,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,SELFPAY,SELF PAY, 650.25,,OUTPCT LIMIT, 601.46,OTHER, 382.87, 849.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31917,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,SELFPAY,SELF PAY, 2027.25,,OUTPCT LIMIT, 2228.68,OTHER, 1193.64, 2648.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31918,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,SELFPAY,SELF PAY, 2202.00,,OUTPCT LIMIT, 2329.49,OTHER, 1296.54, 2877.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31919,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,SELFPAY,SELF PAY, 96.00,,OUTPCT LIMIT, 163.86,OTHER, 56.52, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31920,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,SELFPAY,SELF PAY, 253.43,,OUTPCT LIMIT, 200.99,OTHER, 145.30, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31921,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,SELFPAY,SELF PAY, 90.75,,OUTPCT LIMIT, 93.03,OTHER, 53.43, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31922,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,SELFPAY,SELF PAY, 9.75,,OUTPCT LIMIT, 22.22,OTHER, 5.74, 43.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31923,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,SELFPAY,SELF PAY, 249.00,,OUTPCT LIMIT, 224.77,OTHER, 146.61, 325.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31924,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,SELFPAY,SELF PAY, 132.00,,OUTPCT LIMIT, 251.63,OTHER, 77.72, 451.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31925,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,SELFPAY,SELF PAY, 410.25,,OUTPCT LIMIT, 1148.36,OTHER, 241.56, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31926,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,SELFPAY,SELF PAY, 972.75,,OUTPCT LIMIT, 1534.16,OTHER, 572.76, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31927,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,SELFPAY,SELF PAY, 207.75,,OUTPCT LIMIT, 232.01,OTHER, 122.32, 271.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31928,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,SELFPAY,SELF PAY, 99.45,,OUTPCT LIMIT, 124.43,OTHER, 57.02, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31929,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,SELFPAY,SELF PAY, 93.00,,OUTPCT LIMIT, 120.23,OTHER, 53.32, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31930,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,SELFPAY,SELF PAY, 108.38,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31931,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,SELFPAY,SELF PAY, 108.38,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31932,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,SELFPAY,SELF PAY, 6394.50,,OUTPCT LIMIT, 5204.99,OTHER, 2293.79, 8355.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31933,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,SELFPAY,SELF PAY, 466.50,,OUTPCT LIMIT, 932.84,OTHER, 274.68, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31934,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,SELFPAY,SELF PAY, 592.65,,OUTPCT LIMIT, 424.57,OTHER, 162.56, 774.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31935,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,SELFPAY,SELF PAY, 454.91,,OUTPCT LIMIT, 334.89,OTHER, 162.56, 594.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31936,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,SELFPAY,SELF PAY, 866.12,,OUTPCT LIMIT, 675.88,OTHER, 470.23, 1131.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31937,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,SELFPAY,SELF PAY, 708.15,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31938,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,SELFPAY,SELF PAY, 708.15,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31939,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,SELFPAY,SELF PAY, 259.54,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31940,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,SELFPAY,SELF PAY, 259.54,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31941,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,SELFPAY,SELF PAY, 233.60,,OUTPCT LIMIT, 176.70,OTHER, 103.34, 305.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31942,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,SELFPAY,SELF PAY, 847.46,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31943,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,SELFPAY,SELF PAY, 847.46,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31944,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,SELFPAY,SELF PAY, 1474.46,,OUTPCT LIMIT, 1089.64,OTHER, 544.52, 1926.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31945,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,SELFPAY,SELF PAY, 26.25,,OUTPCT LIMIT, 22.43,OTHER, 15.05, 34.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31946,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,SELFPAY,SELF PAY, 23.29,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31947,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,SELFPAY,SELF PAY, 23.29,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31948,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,SELFPAY,SELF PAY, 23.29,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31949,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,SELFPAY,SELF PAY, 23.29,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31950,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,SELFPAY,SELF PAY, 23.29,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31951,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,SELFPAY,SELF PAY, 23.29,,OUTPCT LIMIT, 20.38,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31952,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,SELFPAY,SELF PAY, 18.75,,OUTPCT LIMIT, 16.02,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31953,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,SELFPAY,SELF PAY, 768.08,,OUTPCT LIMIT, 579.04,OTHER, 331.58, 1003.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31954,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,SELFPAY,SELF PAY, 1654.50,,OUTPCT LIMIT, 1525.88,OTHER, 974.17, 2161.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31955,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,SELFPAY,SELF PAY, 4680.00,,OUTPCT LIMIT, 4097.24,OTHER, 2484.68, 6115.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31956,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,SELFPAY,SELF PAY, 4977.75,,OUTPCT LIMIT, 4480.28,OTHER, 2930.90, 6504.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31957,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,SELFPAY,SELF PAY, 615.75,,OUTPCT LIMIT, 813.44,OTHER, 362.55, 1095.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31958,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,SELFPAY,SELF PAY, 5394.00,,OUTPCT LIMIT, 4090.68,OTHER, 1095.12, 7048.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31959,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,SELFPAY,SELF PAY, 181.19,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31960,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,SELFPAY,SELF PAY, 181.19,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31961,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,SELFPAY,SELF PAY, 474.00,,OUTPCT LIMIT, 1187.28,OTHER, 279.09, 2414.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31962,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,SELFPAY,SELF PAY, 293.25,,OUTPCT LIMIT, 803.17,OTHER, 172.67, 1685.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31963,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,SELFPAY,SELF PAY, 1649.25,,OUTPCT LIMIT, 1733.21,OTHER, 971.08, 2155.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31964,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,SELFPAY,SELF PAY, 2116.50,,OUTPCT LIMIT, 1757.99,OTHER, 857.80, 2765.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31965,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,SELFPAY,SELF PAY, 249.75,,OUTPCT LIMIT, 477.65,OTHER, 147.05, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31966,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,SELFPAY,SELF PAY, 279.00,,OUTPCT LIMIT, 497.71,OTHER, 164.28, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31967,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,SELFPAY,SELF PAY, 1761.75,,OUTPCT LIMIT, 1514.68,OTHER, 857.80, 2302.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31968,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,SELFPAY,SELF PAY, 2489.25,,OUTPCT LIMIT, 2013.65,OTHER, 857.80, 3252.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31969,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,SELFPAY,SELF PAY, 354.75,,OUTPCT LIMIT, 549.67,OTHER, 208.88, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31970,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,SELFPAY,SELF PAY, 396.75,,OUTPCT LIMIT, 578.48,OTHER, 233.61, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31971,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,SELFPAY,SELF PAY, 2067.00,,OUTPCT LIMIT, 2205.29,OTHER, 1217.05, 2700.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31972,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,SELFPAY,SELF PAY, 2531.25,,OUTPCT LIMIT, 2700.60,OTHER, 1490.40, 3307.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31973,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,SELFPAY,SELF PAY, 874.67,,OUTPCT LIMIT, 718.33,OTHER, 501.48, 1142.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31974,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,SELFPAY,SELF PAY, 2284.50,,OUTPCT LIMIT, 2437.34,OTHER, 1345.11, 2985.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31975,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,SELFPAY,SELF PAY, 1208.25,,OUTPCT LIMIT, 1780.93,OTHER, 711.42, 2666.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31976,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,SELFPAY,SELF PAY, 1124.25,,OUTPCT LIMIT, 2411.76,OTHER, 661.96, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31977,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,SELFPAY,SELF PAY, 118.50,,OUTPCT LIMIT, 283.55,OTHER, 69.77, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31978,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,SELFPAY,SELF PAY, 141.00,,OUTPCT LIMIT, 298.98,OTHER, 83.02, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31979,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,SELFPAY,SELF PAY, 231.75,,OUTPCT LIMIT, 482.77,OTHER, 136.45, 906.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31980,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,SELFPAY,SELF PAY, 415.50,,OUTPCT LIMIT, 603.90,OTHER, 244.65, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31981,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,SELFPAY,SELF PAY, 486.75,,OUTPCT LIMIT, 652.77,OTHER, 286.60, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31982,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,SELFPAY,SELF PAY, 634.50,,OUTPCT LIMIT, 754.11,OTHER, 373.59, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31983,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,SELFPAY,SELF PAY, 579.00,,OUTPCT LIMIT, 716.04,OTHER, 340.92, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31984,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,SELFPAY,SELF PAY, 558.00,,OUTPCT LIMIT, 701.64,OTHER, 328.55, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31985,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,SELFPAY,SELF PAY, 2852.25,,OUTPCT LIMIT, 2366.55,OTHER, 1148.80, 3726.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31986,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,SELFPAY,SELF PAY, 188.25,,OUTPCT LIMIT, 623.49,OTHER, 110.84, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31987,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,SELFPAY,SELF PAY, 270.75,,OUTPCT LIMIT, 256.43,OTHER, 159.42, 353.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31988,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,SELFPAY,SELF PAY, 208.50,,OUTPCT LIMIT, 637.38,OTHER, 122.76, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31989,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,SELFPAY,SELF PAY, 208.50,,OUTPCT LIMIT, 982.61,OTHER, 122.76, 2350.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31990,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,SELFPAY,SELF PAY, 1111.50,,OUTPCT LIMIT, 1507.20,OTHER, 654.45, 2085.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31991,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,SELFPAY,SELF PAY, 2807.25,,OUTPCT LIMIT, 3143.54,OTHER, 1652.91, 3668.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31992,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,SELFPAY,SELF PAY, 1233.00,,OUTPCT LIMIT, 2486.35,OTHER, 725.99, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31993,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,SELFPAY,SELF PAY, 1340.25,,OUTPCT LIMIT, 2559.90,OTHER, 789.14, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31994,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,SELFPAY,SELF PAY, 1335.75,,OUTPCT LIMIT, 1425.12,OTHER, 786.49, 1745.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31995,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,SELFPAY,SELF PAY, 2149.50,,OUTPCT LIMIT, 1667.02,OTHER, 539.71, 2808.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31996,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,SELFPAY,SELF PAY, 972.00,,OUTPCT LIMIT, 1786.42,OTHER, 572.31, 3135.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31997,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,SELFPAY,SELF PAY, 2656.50,,OUTPCT LIMIT, 3662.54,OTHER, 1564.15, 5153.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31998,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,SELFPAY,SELF PAY, 274.50,,OUTPCT LIMIT, 889.66,OTHER, 161.63, 1963.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 31999,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,SELFPAY,SELF PAY, 302.21,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32000,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,SELFPAY,SELF PAY, 302.21,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32001,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,SELFPAY,SELF PAY, 2043.00,,OUTPCT LIMIT, 2146.09,OTHER, 1202.92, 2669.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32002,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 199.77,OTHER, 96.75, 377.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32003,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 266.50,OTHER, 96.75, 657.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32004,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,SELFPAY,SELF PAY, 2578.50,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32005,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,SELFPAY,SELF PAY, 2578.50,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32006,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,SELFPAY,SELF PAY, 842.14,,OUTPCT LIMIT, 719.65,OTHER, 482.83, 1100.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32007,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,SELFPAY,SELF PAY, 1506.41,,OUTPCT LIMIT, 1287.31,OTHER, 863.68, 1968.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32008,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,SELFPAY,SELF PAY, 340.43,,OUTPCT LIMIT, 290.91,OTHER, 195.18, 444.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32009,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,SELFPAY,SELF PAY, 1270.50,,OUTPCT LIMIT, 2579.17,OTHER, 748.07, 4781.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32010,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,SELFPAY,SELF PAY, 195.84,,OUTPCT LIMIT, 162.43,OTHER, 112.28, 255.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32011,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,SELFPAY,SELF PAY, 169.56,,OUTPCT LIMIT, 145.32,OTHER, 97.21, 221.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32012,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,SELFPAY,SELF PAY, 108.30,,OUTPCT LIMIT, 116.13,OTHER, 62.09, 191.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32013,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,SELFPAY,SELF PAY, 89.25,,OUTPCT LIMIT, 76.24,OTHER, 51.17, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32014,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,SELFPAY,SELF PAY, 159.80,,OUTPCT LIMIT, 124.60,OTHER, 86.34, 208.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32015,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32016,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,SELFPAY,SELF PAY, 64.50,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32017,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32018,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,SELFPAY,SELF PAY, 102.75,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32019,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32020,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,SELFPAY,SELF PAY, 197.45,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32021,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32022,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,SELFPAY,SELF PAY, 64.50,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32023,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32024,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,SELFPAY,SELF PAY, 213.58,,OUTPCT LIMIT, 171.96,OTHER, 122.45, 279.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32025,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32026,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,SELFPAY,SELF PAY, 164.63,,OUTPCT LIMIT, 127.74,OTHER, 86.34, 215.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32027,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32028,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,SELFPAY,SELF PAY, 240.65,,OUTPCT LIMIT, 189.58,OTHER, 137.97, 314.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32029,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32030,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,SELFPAY,SELF PAY, 148.00,,OUTPCT LIMIT, 116.92,OTHER, 84.85, 193.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32031,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32032,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,SELFPAY,SELF PAY, 409.52,,OUTPCT LIMIT, 299.54,OTHER, 138.19, 535.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32033,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32034,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,SELFPAY,SELF PAY, 288.96,,OUTPCT LIMIT, 221.04,OTHER, 138.19, 377.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32035,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32036,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,SELFPAY,SELF PAY, 222.00,,OUTPCT LIMIT, 177.44,OTHER, 127.28, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32037,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32038,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,SELFPAY,SELF PAY, 77.80,,OUTPCT LIMIT, 71.21,OTHER, 44.60, 101.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32039,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32040,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,SELFPAY,SELF PAY, 265.71,,OUTPCT LIMIT, 193.56,OTHER, 86.34, 347.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32041,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32042,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,SELFPAY,SELF PAY, 311.70,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32043,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,SELFPAY,SELF PAY, 2196.11,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32044,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,SELFPAY,SELF PAY, 1632.36,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32045,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32046,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32047,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,SELFPAY,SELF PAY, 1678.95,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32048,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,SELFPAY,SELF PAY, 1678.95,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32049,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32050,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32051,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,SELFPAY,SELF PAY, 2196.11,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32052,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,SELFPAY,SELF PAY, 2196.11,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32053,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32054,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32055,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,SELFPAY,SELF PAY, 1363.30,,OUTPCT LIMIT, 955.20,OTHER, 283.82, 1781.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32056,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32057,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,SELFPAY,SELF PAY, 903.80,,OUTPCT LIMIT, 691.35,OTHER, 432.18, 1180.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32058,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32059,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,SELFPAY,SELF PAY, 1185.00,,OUTPCT LIMIT, 887.08,OTHER, 485.27, 1548.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32060,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32061,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,SELFPAY,SELF PAY, 1280.25,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32062,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,SELFPAY,SELF PAY, 1280.54,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32063,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32064,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32065,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,SELFPAY,SELF PAY, 1463.75,,OUTPCT LIMIT, 1055.93,OTHER, 432.18, 1912.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32066,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,SELFPAY,SELF PAY, 1842.74,,OUTPCT LIMIT, 1302.68,OTHER, 432.18, 2407.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32067,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32068,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32069,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,SELFPAY,SELF PAY, 610.50,,OUTPCT LIMIT, 513.03,OTHER, 350.02, 797.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32070,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32071,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,SELFPAY,SELF PAY, 1878.42,,OUTPCT LIMIT, 1290.59,OTHER, 283.82, 2454.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32072,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32073,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,SELFPAY,SELF PAY, 1953.53,,OUTPCT LIMIT, 1374.81,OTHER, 432.18, 2552.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32074,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32075,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,SELFPAY,SELF PAY, 1766.93,,OUTPCT LIMIT, 1265.96,OTHER, 485.27, 2308.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32076,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32077,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,SELFPAY,SELF PAY, 1471.69,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32078,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,SELFPAY,SELF PAY, 1471.69,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32079,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,SELFPAY,SELF PAY, 1471.69,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32080,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32081,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32082,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32083,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,SELFPAY,SELF PAY, 1770.68,,OUTPCT LIMIT, 1270.81,OTHER, 495.38, 2313.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32084,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32085,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,SELFPAY,SELF PAY, 2297.75,,OUTPCT LIMIT, 1681.52,OTHER, 779.04, 3002.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32086,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32087,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,SELFPAY,SELF PAY, 1695.29,,OUTPCT LIMIT, 1224.87,OTHER, 508.57, 2215.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32088,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32089,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,SELFPAY,SELF PAY, 1808.25,,OUTPCT LIMIT, 1324.21,OTHER, 616.91, 2362.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32090,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32091,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,SELFPAY,SELF PAY, 2069.63,,OUTPCT LIMIT, 1532.99,OTHER, 779.04, 2704.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32092,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32093,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,SELFPAY,SELF PAY, 1708.69,,OUTPCT LIMIT, 1233.59,OTHER, 508.57, 2232.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32094,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32095,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,SELFPAY,SELF PAY, 1704.00,,OUTPCT LIMIT, 1256.33,OTHER, 616.91, 2226.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32096,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32097,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,SELFPAY,SELF PAY, 1959.19,,OUTPCT LIMIT, 1461.09,OTHER, 779.04, 2560.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32098,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32099,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,SELFPAY,SELF PAY, 1985.26,,OUTPCT LIMIT, 1413.66,OTHER, 508.57, 2594.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32100,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32101,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,SELFPAY,SELF PAY, 3065.19,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32102,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,SELFPAY,SELF PAY, 3065.19,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32103,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32104,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32105,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,SELFPAY,SELF PAY, 64.50,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32106,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,SELFPAY,SELF PAY, 64.50,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32107,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,SELFPAY,SELF PAY, 64.50,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32108,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,SELFPAY,SELF PAY, 64.50,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32109,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32110,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32111,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32112,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32113,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,SELFPAY,SELF PAY, 64.50,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32114,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32115,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,SELFPAY,SELF PAY, 64.50,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32116,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,SELFPAY,SELF PAY, 64.50,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32117,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32118,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32119,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,SELFPAY,SELF PAY, 340.19,,OUTPCT LIMIT, 242.05,OTHER, 86.34, 444.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32120,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,SELFPAY,SELF PAY, 342.44,,OUTPCT LIMIT, 243.52,OTHER, 86.34, 447.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32121,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32122,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32123,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,SELFPAY,SELF PAY, 278.36,,OUTPCT LIMIT, 214.14,OTHER, 138.19, 363.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32124,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,SELFPAY,SELF PAY, 318.12,,OUTPCT LIMIT, 240.03,OTHER, 138.19, 415.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32125,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32126,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32127,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,SELFPAY,SELF PAY, 331.70,,OUTPCT LIMIT, 248.87,OTHER, 138.19, 433.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32128,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32129,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,SELFPAY,SELF PAY, 222.00,,OUTPCT LIMIT, 165.10,OTHER, 86.34, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32130,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32131,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,SELFPAY,SELF PAY, 64.50,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32132,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32133,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,SELFPAY,SELF PAY, 1756.80,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32134,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,SELFPAY,SELF PAY, 1756.80,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32135,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,SELFPAY,SELF PAY, 1756.80,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32136,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32137,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32138,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,SELFPAY,SELF PAY, 1756.80,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32139,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,SELFPAY,SELF PAY, 2095.14,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32140,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32141,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,SELFPAY,SELF PAY, 2613.65,,OUTPCT LIMIT, 1817.25,OTHER, 485.27, 3415.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32142,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32143,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,SELFPAY,SELF PAY, 1756.80,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32144,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,SELFPAY,SELF PAY, 1756.80,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32145,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,SELFPAY,SELF PAY, 1756.80,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32146,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32147,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32148,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32149,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,SELFPAY,SELF PAY, 3735.02,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32150,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,SELFPAY,SELF PAY, 2516.76,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32151,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,SELFPAY,SELF PAY, 2516.76,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32152,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,SELFPAY,SELF PAY, 2516.76,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32153,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,SELFPAY,SELF PAY, 2516.76,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32154,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32155,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32156,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32157,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32158,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,SELFPAY,SELF PAY, 949.50,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32159,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,SELFPAY,SELF PAY, 2118.75,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32160,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32161,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32162,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,SELFPAY,SELF PAY, 228.00,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32163,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,SELFPAY,SELF PAY, 228.00,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32164,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32165,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32166,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,SELFPAY,SELF PAY, 329.84,,OUTPCT LIMIT, 247.65,OTHER, 138.19, 430.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32167,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32168,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,SELFPAY,SELF PAY, 487.95,,OUTPCT LIMIT, 350.60,OTHER, 138.19, 637.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32169,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32170,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,SELFPAY,SELF PAY, 537.14,,OUTPCT LIMIT, 382.63,OTHER, 138.19, 701.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32171,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32172,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,SELFPAY,SELF PAY, 400.25,,OUTPCT LIMIT, 293.50,OTHER, 138.19, 522.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32173,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32174,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,SELFPAY,SELF PAY, 357.80,,OUTPCT LIMIT, 265.86,OTHER, 138.19, 467.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32175,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32176,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,SELFPAY,SELF PAY, 197.45,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32177,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32178,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,SELFPAY,SELF PAY, 187.50,,OUTPCT LIMIT, 142.64,OTHER, 86.34, 245.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32179,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32180,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,SELFPAY,SELF PAY, 64.50,,OUTPCT LIMIT, 63.06,OTHER, 36.98, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32181,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,SELFPAY,SELF PAY, 197.45,,OUTPCT LIMIT, 163.44,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32182,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32183,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,SELFPAY,SELF PAY, 347.63,,OUTPCT LIMIT, 259.24,OTHER, 138.19, 454.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32184,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32185,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,SELFPAY,SELF PAY, 205.82,,OUTPCT LIMIT, 166.91,OTHER, 118.00, 268.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32186,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32187,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,SELFPAY,SELF PAY, 574.70,,OUTPCT LIMIT, 407.08,OTHER, 138.19, 750.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32188,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32189,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,SELFPAY,SELF PAY, 2137.66,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32190,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,SELFPAY,SELF PAY, 2137.66,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32191,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,SELFPAY,SELF PAY, 2137.66,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32192,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32193,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32194,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32195,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,SELFPAY,SELF PAY, 843.75,,OUTPCT LIMIT, 664.89,OTHER, 483.75, 1102.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32196,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32197,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,SELFPAY,SELF PAY, 2429.07,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32198,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,SELFPAY,SELF PAY, 2429.07,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32199,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32200,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32201,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,SELFPAY,SELF PAY, 2400.00,,OUTPCT LIMIT, 1665.51,OTHER, 432.18, 3136.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32202,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32203,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,SELFPAY,SELF PAY, 2106.64,,OUTPCT LIMIT, 1439.18,OTHER, 283.82, 2752.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32204,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32205,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,SELFPAY,SELF PAY, 2380.16,,OUTPCT LIMIT, 1652.58,OTHER, 432.18, 3110.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32206,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32207,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,SELFPAY,SELF PAY, 2250.00,,OUTPCT LIMIT, 1580.48,OTHER, 485.27, 2940.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32208,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32209,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,SELFPAY,SELF PAY, 2443.93,,OUTPCT LIMIT, 1712.29,OTHER, 508.57, 3193.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32210,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32211,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,SELFPAY,SELF PAY, 2724.21,,OUTPCT LIMIT, 1894.78,OTHER, 508.57, 3559.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32212,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32213,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,SELFPAY,SELF PAY, 2391.15,,OUTPCT LIMIT, 1677.93,OTHER, 508.57, 3124.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32214,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32215,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,SELFPAY,SELF PAY, 2970.90,,OUTPCT LIMIT, 2119.80,OTHER, 779.04, 3881.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32216,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32217,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,SELFPAY,SELF PAY, 3615.58,,OUTPCT LIMIT, 2539.54,OTHER, 779.04, 4724.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32218,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32219,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,SELFPAY,SELF PAY, 3386.21,,OUTPCT LIMIT, 2390.20,OTHER, 779.04, 4424.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32220,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32221,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32222,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32223,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32224,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,SELFPAY,SELF PAY, 313.19,,OUTPCT LIMIT, 236.81,OTHER, 138.19, 409.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32225,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32226,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,SELFPAY,SELF PAY, 247.22,,OUTPCT LIMIT, 193.87,OTHER, 138.19, 323.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32227,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32228,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,SELFPAY,SELF PAY, 1833.22,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32229,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,SELFPAY,SELF PAY, 1833.22,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32230,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32231,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32232,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,SELFPAY,SELF PAY, 1771.20,,OUTPCT LIMIT, 1256.10,OTHER, 432.18, 2314.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32233,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32234,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,SELFPAY,SELF PAY, 1196.63,,OUTPCT LIMIT, 894.65,OTHER, 485.27, 1563.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32235,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32236,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,SELFPAY,SELF PAY, 2504.18,,OUTPCT LIMIT, 1751.53,OTHER, 508.57, 3272.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32237,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32238,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,SELFPAY,SELF PAY, 3753.53,,OUTPCT LIMIT, 2629.35,OTHER, 779.04, 4904.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32239,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32240,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,SELFPAY,SELF PAY, 1500.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32241,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,SELFPAY,SELF PAY, 1500.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32242,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,SELFPAY,SELF PAY, 1500.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32243,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32244,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32245,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32246,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,SELFPAY,SELF PAY, 220.60,,OUTPCT LIMIT, 164.19,OTHER, 86.34, 288.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32247,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32248,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,SELFPAY,SELF PAY, 313.01,,OUTPCT LIMIT, 224.35,OTHER, 86.34, 408.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32249,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32250,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,SELFPAY,SELF PAY, 288.98,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32251,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,SELFPAY,SELF PAY, 288.98,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32252,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,SELFPAY,SELF PAY, 299.74,,OUTPCT LIMIT, 215.71,OTHER, 86.34, 391.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32253,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32254,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32255,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32256,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,SELFPAY,SELF PAY, 197.45,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32257,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,SELFPAY,SELF PAY, 197.45,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32258,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,SELFPAY,SELF PAY, 197.45,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32259,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32260,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32261,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32262,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,SELFPAY,SELF PAY, 238.50,,OUTPCT LIMIT, 175.84,OTHER, 86.34, 311.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32263,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,SELFPAY,SELF PAY, 228.08,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32264,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,SELFPAY,SELF PAY, 228.08,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32265,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32266,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32267,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32268,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,SELFPAY,SELF PAY, 310.50,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32269,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,SELFPAY,SELF PAY, 310.50,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32270,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,SELFPAY,SELF PAY, 318.63,,OUTPCT LIMIT, 240.36,OTHER, 138.19, 416.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32271,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32272,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32273,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32274,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,SELFPAY,SELF PAY, 305.87,,OUTPCT LIMIT, 219.70,OTHER, 86.34, 399.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32275,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,SELFPAY,SELF PAY, 297.80,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32276,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,SELFPAY,SELF PAY, 297.80,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32277,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32278,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32279,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32280,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,SELFPAY,SELF PAY, 285.68,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32281,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,SELFPAY,SELF PAY, 293.74,,OUTPCT LIMIT, 211.81,OTHER, 86.34, 383.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32282,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,SELFPAY,SELF PAY, 285.68,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32283,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32284,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32285,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32286,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,SELFPAY,SELF PAY, 321.75,,OUTPCT LIMIT, 230.04,OTHER, 86.34, 420.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32287,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,SELFPAY,SELF PAY, 311.70,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32288,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32289,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32290,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32291,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,SELFPAY,SELF PAY, 322.95,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32292,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,SELFPAY,SELF PAY, 322.95,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32293,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,SELFPAY,SELF PAY, 333.00,,OUTPCT LIMIT, 237.37,OTHER, 86.34, 435.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32294,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32295,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32296,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32297,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,SELFPAY,SELF PAY, 102.75,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32298,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,SELFPAY,SELF PAY, 142.50,,OUTPCT LIMIT, 125.68,OTHER, 81.70, 186.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32299,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,SELFPAY,SELF PAY, 102.75,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32300,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32301,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32302,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32303,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,SELFPAY,SELF PAY, 296.70,,OUTPCT LIMIT, 213.73,OTHER, 86.34, 387.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32304,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,SELFPAY,SELF PAY, 287.48,,OUTPCT LIMIT, 207.73,OTHER, 86.34, 375.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32305,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,SELFPAY,SELF PAY, 287.49,,OUTPCT LIMIT, 207.74,OTHER, 86.34, 375.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32306,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32307,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32308,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32309,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,SELFPAY,SELF PAY, 334.25,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32310,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,SELFPAY,SELF PAY, 342.32,,OUTPCT LIMIT, 243.44,OTHER, 86.34, 447.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32311,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,SELFPAY,SELF PAY, 334.25,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32312,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32313,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32314,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32315,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,SELFPAY,SELF PAY, 315.75,,OUTPCT LIMIT, 238.48,OTHER, 138.19, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32316,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,SELFPAY,SELF PAY, 305.70,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32317,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,SELFPAY,SELF PAY, 305.70,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32318,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32319,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32320,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32321,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,SELFPAY,SELF PAY, 306.87,,OUTPCT LIMIT, 220.36,OTHER, 86.34, 400.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32322,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,SELFPAY,SELF PAY, 306.97,,OUTPCT LIMIT, 220.42,OTHER, 86.34, 401.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32323,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,SELFPAY,SELF PAY, 315.03,,OUTPCT LIMIT, 225.67,OTHER, 86.34, 411.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32324,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32325,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32326,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32327,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,SELFPAY,SELF PAY, 255.68,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32328,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,SELFPAY,SELF PAY, 236.74,,OUTPCT LIMIT, 174.69,OTHER, 86.34, 309.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32329,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,SELFPAY,SELF PAY, 228.68,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32330,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,SELFPAY,SELF PAY, 228.68,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32331,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,SELFPAY,SELF PAY, 228.68,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32332,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,SELFPAY,SELF PAY, 228.68,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32333,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,SELFPAY,SELF PAY, 228.68,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32334,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,SELFPAY,SELF PAY, 228.68,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32335,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,SELFPAY,SELF PAY, 228.68,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32336,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,SELFPAY,SELF PAY, 228.68,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32337,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,SELFPAY,SELF PAY, 228.68,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32338,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,SELFPAY,SELF PAY, 228.68,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32339,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,SELFPAY,SELF PAY, 228.68,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32340,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32341,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32342,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32343,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32344,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32345,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32346,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32347,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32348,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32349,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32350,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32351,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32352,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32353,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,SELFPAY,SELF PAY, 1418.75,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32354,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,SELFPAY,SELF PAY, 1525.89,,OUTPCT LIMIT, 1061.06,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32355,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,SELFPAY,SELF PAY, 1525.89,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32356,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,SELFPAY,SELF PAY, 1525.89,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32357,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,SELFPAY,SELF PAY, 1525.89,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32358,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,SELFPAY,SELF PAY, 1525.89,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32359,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,SELFPAY,SELF PAY, 1525.89,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32360,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,SELFPAY,SELF PAY, 501.75,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32361,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,SELFPAY,SELF PAY, 501.75,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32362,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,SELFPAY,SELF PAY, 1525.89,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32363,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,SELFPAY,SELF PAY, 1525.89,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32364,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,SELFPAY,SELF PAY, 501.75,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32365,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,SELFPAY,SELF PAY, 1525.89,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32366,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,SELFPAY,SELF PAY, 1525.89,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32367,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,SELFPAY,SELF PAY, 1418.75,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32368,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32369,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32370,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32371,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32372,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32373,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32374,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32375,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32376,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32377,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32378,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32379,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32380,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32381,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32382,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,SELFPAY,SELF PAY, 2121.74,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32383,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,SELFPAY,SELF PAY, 2121.74,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32384,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32385,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32386,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32387,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,SELFPAY,SELF PAY, 1011.75,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32388,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,SELFPAY,SELF PAY, 1011.75,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32389,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32390,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32391,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,SELFPAY,SELF PAY, 1435.24,,OUTPCT LIMIT, 1055.55,OTHER, 508.57, 1875.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32392,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32393,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,SELFPAY,SELF PAY, 2475.19,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32394,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,SELFPAY,SELF PAY, 2475.19,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32395,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,SELFPAY,SELF PAY, 2475.19,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32396,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32397,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32398,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32399,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,SELFPAY,SELF PAY, 2523.50,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32400,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,SELFPAY,SELF PAY, 2523.50,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32401,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,SELFPAY,SELF PAY, 2523.50,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32402,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,SELFPAY,SELF PAY, 2523.50,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32403,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,SELFPAY,SELF PAY, 2523.50,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32404,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,SELFPAY,SELF PAY, 2523.50,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32405,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,SELFPAY,SELF PAY, 2523.50,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32406,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,SELFPAY,SELF PAY, 2523.50,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32407,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,SELFPAY,SELF PAY, 2523.50,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32408,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,SELFPAY,SELF PAY, 2523.50,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32409,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,SELFPAY,SELF PAY, 2523.50,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32410,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,SELFPAY,SELF PAY, 2523.50,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32411,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,SELFPAY,SELF PAY, 2523.50,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32412,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,SELFPAY,SELF PAY, 2523.50,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32413,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,SELFPAY,SELF PAY, 2523.50,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32414,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,SELFPAY,SELF PAY, 2523.50,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32415,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32416,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32417,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32418,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32419,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32420,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32421,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32422,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32423,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32424,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32425,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32426,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32427,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32428,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32429,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32430,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32431,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,SELFPAY,SELF PAY, 1942.69,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32432,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,SELFPAY,SELF PAY, 1942.69,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32433,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32434,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32435,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32436,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32437,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32438,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32439,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,SELFPAY,SELF PAY, 270.21,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32440,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,SELFPAY,SELF PAY, 270.21,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32441,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,SELFPAY,SELF PAY, 270.21,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32442,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32443,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32444,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32445,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,SELFPAY,SELF PAY, 260.98,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32446,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,SELFPAY,SELF PAY, 260.98,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32447,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,SELFPAY,SELF PAY, 260.98,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32448,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,SELFPAY,SELF PAY, 260.98,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32449,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,SELFPAY,SELF PAY, 260.98,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32450,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32451,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32452,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32453,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32454,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,SELFPAY,SELF PAY, 341.39,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32455,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,SELFPAY,SELF PAY, 271.48,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32456,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32457,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32458,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,SELFPAY,SELF PAY, 279.41,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32459,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,SELFPAY,SELF PAY, 279.41,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32460,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,SELFPAY,SELF PAY, 287.47,,OUTPCT LIMIT, 208.23,OTHER, 88.46, 375.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32461,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32462,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32463,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32464,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,SELFPAY,SELF PAY, 292.08,,OUTPCT LIMIT, 210.73,OTHER, 86.34, 381.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32465,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,SELFPAY,SELF PAY, 282.87,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32466,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,SELFPAY,SELF PAY, 282.87,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32467,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32468,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32469,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32470,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,SELFPAY,SELF PAY, 362.87,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32471,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,SELFPAY,SELF PAY, 370.94,,OUTPCT LIMIT, 274.41,OTHER, 138.19, 484.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32472,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,SELFPAY,SELF PAY, 362.87,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32473,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32474,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32475,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32476,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,SELFPAY,SELF PAY, 567.00,,OUTPCT LIMIT, 402.07,OTHER, 138.19, 740.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32477,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,SELFPAY,SELF PAY, 556.69,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32478,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,SELFPAY,SELF PAY, 556.69,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32479,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32480,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32481,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32482,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,SELFPAY,SELF PAY, 203.99,,OUTPCT LIMIT, 153.37,OTHER, 86.34, 266.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32483,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32484,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,SELFPAY,SELF PAY, 341.76,,OUTPCT LIMIT, 243.07,OTHER, 86.34, 446.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32485,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,SELFPAY,SELF PAY, 333.70,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32486,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,SELFPAY,SELF PAY, 333.70,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32487,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32488,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32489,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32490,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,SELFPAY,SELF PAY, 64.50,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32491,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,SELFPAY,SELF PAY, 64.50,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32492,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,SELFPAY,SELF PAY, 129.00,,OUTPCT LIMIT, 116.89,OTHER, 73.96, 168.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32493,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32494,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32495,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32496,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,SELFPAY,SELF PAY, 285.74,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32497,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,SELFPAY,SELF PAY, 285.74,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32498,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,SELFPAY,SELF PAY, 295.50,,OUTPCT LIMIT, 225.30,OTHER, 138.19, 386.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32499,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32500,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32501,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32502,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,SELFPAY,SELF PAY, 323.25,,OUTPCT LIMIT, 243.37,OTHER, 138.19, 422.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32503,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,SELFPAY,SELF PAY, 313.11,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32504,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,SELFPAY,SELF PAY, 313.11,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32505,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32506,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32507,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32508,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,SELFPAY,SELF PAY, 254.97,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32509,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,SELFPAY,SELF PAY, 254.97,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32510,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32511,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32512,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,SELFPAY,SELF PAY, 352.70,,OUTPCT LIMIT, 250.19,OTHER, 86.34, 460.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32513,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,SELFPAY,SELF PAY, 344.48,,OUTPCT LIMIT, 244.84,OTHER, 86.34, 450.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32514,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,SELFPAY,SELF PAY, 344.63,,OUTPCT LIMIT, 244.94,OTHER, 86.34, 450.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32515,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32516,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32517,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32518,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,SELFPAY,SELF PAY, 174.75,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32519,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,SELFPAY,SELF PAY, 174.75,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32520,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,SELFPAY,SELF PAY, 174.75,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32521,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32522,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32523,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32524,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,SELFPAY,SELF PAY, 233.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32525,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,SELFPAY,SELF PAY, 233.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32526,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,SELFPAY,SELF PAY, 233.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32527,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,SELFPAY,SELF PAY, 233.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32528,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,SELFPAY,SELF PAY, 233.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32529,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,SELFPAY,SELF PAY, 233.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32530,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,SELFPAY,SELF PAY, 233.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32531,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,SELFPAY,SELF PAY, 233.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32532,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 179.26,OTHER, 86.34, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32533,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,SELFPAY,SELF PAY, 233.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32534,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,SELFPAY,SELF PAY, 233.35,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32535,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32536,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32537,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32538,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32539,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32540,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32541,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32542,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32543,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32544,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32545,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32546,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,SELFPAY,SELF PAY, 1718.96,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32547,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,SELFPAY,SELF PAY, 1718.96,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32548,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,SELFPAY,SELF PAY, 1718.96,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32549,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,SELFPAY,SELF PAY, 1728.75,,OUTPCT LIMIT, 1193.14,OTHER, 283.82, 2258.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32550,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,SELFPAY,SELF PAY, 1718.96,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32551,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,SELFPAY,SELF PAY, 1718.96,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32552,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,SELFPAY,SELF PAY, 1718.96,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32553,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,SELFPAY,SELF PAY, 1718.96,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32554,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,SELFPAY,SELF PAY, 1718.96,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32555,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,SELFPAY,SELF PAY, 1718.96,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32556,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,SELFPAY,SELF PAY, 1718.96,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32557,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,SELFPAY,SELF PAY, 1718.96,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32558,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,SELFPAY,SELF PAY, 1718.96,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32559,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,SELFPAY,SELF PAY, 1718.96,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32560,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32561,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32562,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32563,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32564,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32565,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32566,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32567,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32568,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32569,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32570,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32571,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32572,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32573,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32574,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,SELFPAY,SELF PAY, 2046.00,,OUTPCT LIMIT, 1435.02,OTHER, 432.18, 2673.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32575,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,SELFPAY,SELF PAY, 2035.82,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32576,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,SELFPAY,SELF PAY, 2035.82,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32577,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32578,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32579,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32580,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,SELFPAY,SELF PAY, 1011.75,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32581,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,SELFPAY,SELF PAY, 1011.75,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32582,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,SELFPAY,SELF PAY, 1011.75,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32583,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32584,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32585,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32586,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,SELFPAY,SELF PAY, 1041.75,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32587,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,SELFPAY,SELF PAY, 1041.75,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32588,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32589,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32590,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,SELFPAY,SELF PAY, 2219.21,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32591,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,SELFPAY,SELF PAY, 2219.21,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32592,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,SELFPAY,SELF PAY, 2219.21,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32593,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,SELFPAY,SELF PAY, 2219.21,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32594,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,SELFPAY,SELF PAY, 2219.21,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32595,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,SELFPAY,SELF PAY, 2219.21,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32596,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32597,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32598,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32599,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32600,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32601,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32602,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,SELFPAY,SELF PAY, 2715.29,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32603,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,SELFPAY,SELF PAY, 2715.29,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32604,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32605,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32606,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,SELFPAY,SELF PAY, 2365.30,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32607,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,SELFPAY,SELF PAY, 2365.30,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32608,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,SELFPAY,SELF PAY, 2365.31,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32609,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,SELFPAY,SELF PAY, 2365.31,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32610,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,SELFPAY,SELF PAY, 2365.30,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32611,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,SELFPAY,SELF PAY, 2365.30,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32612,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,SELFPAY,SELF PAY, 2365.30,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32613,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,SELFPAY,SELF PAY, 2365.30,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32614,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,SELFPAY,SELF PAY, 2365.30,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32615,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,SELFPAY,SELF PAY, 2365.30,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32616,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32617,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32618,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32619,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32620,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32621,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32622,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32623,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32624,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32625,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32626,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,SELFPAY,SELF PAY, 3452.18,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32627,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,SELFPAY,SELF PAY, 3452.18,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32628,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,SELFPAY,SELF PAY, 3452.18,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32629,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,SELFPAY,SELF PAY, 3452.18,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32630,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,SELFPAY,SELF PAY, 3452.18,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32631,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32632,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32633,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32634,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32635,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32636,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,SELFPAY,SELF PAY, 1500.00,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32637,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,SELFPAY,SELF PAY, 1725.00,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32638,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,SELFPAY,SELF PAY, 1725.00,,OUTPCT LIMIT, 1474.10,OTHER, 989.00, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32639,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,SELFPAY,SELF PAY, 1372.50,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32640,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,SELFPAY,SELF PAY, 1372.50,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32641,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32642,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32643,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32644,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32645,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32646,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,SELFPAY,SELF PAY, 124.50,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32647,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,SELFPAY,SELF PAY, 124.50,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32648,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32649,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32650,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,SELFPAY,SELF PAY, 64.50,,OUTPCT LIMIT, 83.13,OTHER, 36.98, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32651,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 105.42,OTHER, 37.54, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32652,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,SELFPAY,SELF PAY, 444.69,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32653,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,SELFPAY,SELF PAY, 444.69,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32654,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32655,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32656,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,SELFPAY,SELF PAY, 1963.57,,OUTPCT LIMIT, 1346.03,OTHER, 283.82, 2565.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32657,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32658,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,SELFPAY,SELF PAY, 2213.72,,OUTPCT LIMIT, 1544.22,OTHER, 432.18, 2892.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32659,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32660,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,SELFPAY,SELF PAY, 2499.92,,OUTPCT LIMIT, 1743.20,OTHER, 485.27, 3266.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32661,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32662,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,SELFPAY,SELF PAY, 4485.02,,OUTPCT LIMIT, 3113.75,OTHER, 813.20, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32663,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,SELFPAY,SELF PAY, 266.25,,OUTPCT LIMIT, 473.04,OTHER, 156.77, 813.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32664,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,SELFPAY,SELF PAY, 2496.62,,OUTPCT LIMIT, 1743.46,OTHER, 495.38, 3262.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32665,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32666,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,SELFPAY,SELF PAY, 3906.91,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32667,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,SELFPAY,SELF PAY, 3906.91,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32668,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32669,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32670,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,SELFPAY,SELF PAY, 4485.02,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32671,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,SELFPAY,SELF PAY, 4485.02,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32672,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32673,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32674,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,SELFPAY,SELF PAY, 5025.16,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32675,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,SELFPAY,SELF PAY, 5025.16,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32676,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,SELFPAY,SELF PAY, 5025.16,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32677,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32678,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32679,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32680,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,SELFPAY,SELF PAY, 2409.19,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32681,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,SELFPAY,SELF PAY, 2409.19,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32682,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32683,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32684,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,SELFPAY,SELF PAY, 2536.64,,OUTPCT LIMIT, 1837.06,OTHER, 779.04, 3314.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32685,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32686,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,SELFPAY,SELF PAY, 1875.00,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32687,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,SELFPAY,SELF PAY, 3036.00,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32688,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32689,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32690,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32691,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,SELFPAY,SELF PAY, 523.50,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32692,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,SELFPAY,SELF PAY, 523.50,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32693,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,SELFPAY,SELF PAY, 523.50,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32694,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32695,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32696,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,SELFPAY,SELF PAY, 823.90,,OUTPCT LIMIT, 704.06,OTHER, 472.37, 1076.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32697,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 68.02,OTHER, 37.54, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32698,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,SELFPAY,SELF PAY, 289.80,,OUTPCT LIMIT, 248.14,OTHER, 166.15, 378.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32699,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 230.64,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32700,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,SELFPAY,SELF PAY, 568.94,,OUTPCT LIMIT, 429.88,OTHER, 249.71, 743.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32701,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 132.91,OTHER, 37.54, 249.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32702,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,SELFPAY,SELF PAY, 2115.89,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32703,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,SELFPAY,SELF PAY, 2115.89,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32704,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32705,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32706,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,SELFPAY,SELF PAY, 262.50,,OUTPCT LIMIT, 224.32,OTHER, 150.50, 343.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32707,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32708,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,SELFPAY,SELF PAY, 540.37,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32709,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,SELFPAY,SELF PAY, 540.37,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32710,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,SELFPAY,SELF PAY, 540.37,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32711,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32712,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32713,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32714,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,SELFPAY,SELF PAY, 406.94,,OUTPCT LIMIT, 286.59,OTHER, 90.89, 531.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32715,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32716,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,SELFPAY,SELF PAY, 383.50,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32717,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,SELFPAY,SELF PAY, 383.50,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32718,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,SELFPAY,SELF PAY, 383.50,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32719,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,SELFPAY,SELF PAY, 393.75,,OUTPCT LIMIT, 288.12,OTHER, 133.37, 514.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32720,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32721,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32722,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32723,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32724,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,SELFPAY,SELF PAY, 721.54,,OUTPCT LIMIT, 503.49,OTHER, 141.55, 942.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32725,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32726,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,SELFPAY,SELF PAY, 658.95,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32727,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,SELFPAY,SELF PAY, 658.95,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32728,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,SELFPAY,SELF PAY, 658.95,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32729,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,SELFPAY,SELF PAY, 658.95,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32730,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,SELFPAY,SELF PAY, 658.95,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32731,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32732,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32733,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32734,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32735,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32736,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,SELFPAY,SELF PAY, 658.95,,OUTPCT LIMIT, 468.07,OTHER, 163.97, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32737,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 200.02,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32738,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,SELFPAY,SELF PAY, 594.30,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32739,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,SELFPAY,SELF PAY, 594.30,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32740,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,SELFPAY,SELF PAY, 594.30,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32741,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,SELFPAY,SELF PAY, 594.30,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32742,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,SELFPAY,SELF PAY, 584.87,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32743,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32744,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32745,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32746,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32747,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32748,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,SELFPAY,SELF PAY, 584.87,,OUTPCT LIMIT, 414.50,OTHER, 141.55, 764.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32749,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32750,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,SELFPAY,SELF PAY, 281.25,,OUTPCT LIMIT, 214.87,OTHER, 133.37, 367.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32751,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 163.37,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32752,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,SELFPAY,SELF PAY, 576.01,,OUTPCT LIMIT, 408.73,OTHER, 141.55, 752.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32753,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32754,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,SELFPAY,SELF PAY, 727.79,,OUTPCT LIMIT, 507.55,OTHER, 141.55, 950.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32755,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32756,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,SELFPAY,SELF PAY, 1158.00,,OUTPCT LIMIT, 775.60,OTHER, 90.89, 1513.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32757,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32758,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,SELFPAY,SELF PAY, 397.50,,OUTPCT LIMIT, 290.56,OTHER, 133.37, 519.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32759,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32760,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,SELFPAY,SELF PAY, 592.97,,OUTPCT LIMIT, 419.77,OTHER, 141.55, 774.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32761,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32762,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,SELFPAY,SELF PAY, 672.54,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32763,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,SELFPAY,SELF PAY, 672.54,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32764,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,SELFPAY,SELF PAY, 672.54,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32765,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32766,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32767,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32768,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,SELFPAY,SELF PAY, 469.31,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32769,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,SELFPAY,SELF PAY, 453.69,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32770,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32771,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32772,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,SELFPAY,SELF PAY, 575.61,,OUTPCT LIMIT, 408.48,OTHER, 141.55, 752.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32773,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32774,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,SELFPAY,SELF PAY, 1200.00,,OUTPCT LIMIT, 813.95,OTHER, 137.10, 1568.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32775,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,SELFPAY,SELF PAY, 758.73,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32776,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,SELFPAY,SELF PAY, 758.73,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32777,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32778,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32779,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32780,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,SELFPAY,SELF PAY, 269.22,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32781,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,SELFPAY,SELF PAY, 412.50,,OUTPCT LIMIT, 300.33,OTHER, 133.37, 539.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32782,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,SELFPAY,SELF PAY, 269.22,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32783,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,SELFPAY,SELF PAY, 269.22,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32784,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,SELFPAY,SELF PAY, 269.22,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32785,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,SELFPAY,SELF PAY, 269.22,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32786,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,SELFPAY,SELF PAY, 269.22,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32787,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,SELFPAY,SELF PAY, 269.22,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32788,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,SELFPAY,SELF PAY, 269.22,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32789,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32790,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32791,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32792,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32793,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32794,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32795,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32796,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32797,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32798,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,SELFPAY,SELF PAY, 498.67,,OUTPCT LIMIT, 426.14,OTHER, 285.90, 651.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32799,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32800,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,SELFPAY,SELF PAY, 318.44,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32801,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,SELFPAY,SELF PAY, 318.44,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32802,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,SELFPAY,SELF PAY, 318.44,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32803,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,SELFPAY,SELF PAY, 267.75,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32804,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32805,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,SELFPAY,SELF PAY, 267.75,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32806,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,SELFPAY,SELF PAY, 267.75,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32807,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,SELFPAY,SELF PAY, 218.25,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32808,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,SELFPAY,SELF PAY, 218.25,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32809,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,SELFPAY,SELF PAY, 106.50,,OUTPCT LIMIT, 91.01,OTHER, 61.06, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32810,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,SELFPAY,SELF PAY, 138.75,,OUTPCT LIMIT, 78.82,OTHER, 21.15, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32811,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,SELFPAY,SELF PAY, 218.25,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32812,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,SELFPAY,SELF PAY, 218.25,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32813,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,SELFPAY,SELF PAY, 218.25,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32814,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,SELFPAY,SELF PAY, 218.25,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32815,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32816,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32817,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32818,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32819,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,SELFPAY,SELF PAY, 367.50,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32820,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,SELFPAY,SELF PAY, 306.75,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32821,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,SELFPAY,SELF PAY, 367.50,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32822,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32823,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32824,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,SELFPAY,SELF PAY, 218.25,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32825,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,SELFPAY,SELF PAY, 218.25,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32826,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,SELFPAY,SELF PAY, 218.25,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32827,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,SELFPAY,SELF PAY, 218.25,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32828,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,SELFPAY,SELF PAY, 450.00,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32829,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,SELFPAY,SELF PAY, 311.25,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32830,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,SELFPAY,SELF PAY, 311.25,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32831,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32832,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32833,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32834,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32835,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32836,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32837,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32838,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,SELFPAY,SELF PAY, 128.25,,OUTPCT LIMIT, 116.40,OTHER, 73.53, 167.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32839,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,SELFPAY,SELF PAY, 31.50,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32840,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,SELFPAY,SELF PAY, 551.12,,OUTPCT LIMIT, 414.07,OTHER, 232.03, 720.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32841,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,SELFPAY,SELF PAY, 147.00,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32842,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,SELFPAY,SELF PAY, 263.25,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32843,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,SELFPAY,SELF PAY, 31.50,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32844,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,SELFPAY,SELF PAY, 31.50,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32845,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,SELFPAY,SELF PAY, 222.00,,OUTPCT LIMIT, 154.63,OTHER, 42.36, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32846,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,SELFPAY,SELF PAY, 263.25,,OUTPCT LIMIT, 204.30,OTHER, 138.19, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32847,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,SELFPAY,SELF PAY, 31.50,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32848,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,SELFPAY,SELF PAY, 957.62,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32849,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,SELFPAY,SELF PAY, 957.62,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32850,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32851,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32852,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,SELFPAY,SELF PAY, 744.42,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32853,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,SELFPAY,SELF PAY, 744.42,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32854,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32855,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32856,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,SELFPAY,SELF PAY, 1046.93,,OUTPCT LIMIT, 757.92,OTHER, 320.35, 1367.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32857,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 230.15,OTHER, 99.36, 320.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32858,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,SELFPAY,SELF PAY, 1264.04,,OUTPCT LIMIT, 899.81,OTHER, 322.62, 1651.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32859,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 230.96,OTHER, 99.36, 322.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32860,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,SELFPAY,SELF PAY, 1477.50,,OUTPCT LIMIT, 1092.65,OTHER, 548.80, 1930.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32861,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 311.74,OTHER, 99.36, 548.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32862,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,SELFPAY,SELF PAY, 1172.35,,OUTPCT LIMIT, 864.03,OTHER, 423.08, 1531.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32863,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32864,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,SELFPAY,SELF PAY, 375.00,,OUTPCT LIMIT, 344.89,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32865,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32866,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,SELFPAY,SELF PAY, 1125.00,,OUTPCT LIMIT, 830.31,OTHER, 410.92, 1470.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32867,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32868,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,SELFPAY,SELF PAY, 1545.00,,OUTPCT LIMIT, 1103.77,OTHER, 410.92, 2018.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32869,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32870,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,SELFPAY,SELF PAY, 1575.00,,OUTPCT LIMIT, 1111.16,OTHER, 359.95, 2058.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32871,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32872,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,SELFPAY,SELF PAY, 826.88,,OUTPCT LIMIT, 624.07,OTHER, 359.95, 1080.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32873,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32874,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,SELFPAY,SELF PAY, 901.00,,OUTPCT LIMIT, 672.34,OTHER, 360.01, 1177.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32875,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32876,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,SELFPAY,SELF PAY, 727.50,,OUTPCT LIMIT, 559.38,OTHER, 360.01, 950.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32877,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32878,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,SELFPAY,SELF PAY, 1754.52,,OUTPCT LIMIT, 1228.06,OTHER, 360.01, 2292.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32879,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32880,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,SELFPAY,SELF PAY, 1855.88,,OUTPCT LIMIT, 1294.05,OTHER, 360.01, 2425.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32881,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32882,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,SELFPAY,SELF PAY, 821.25,,OUTPCT LIMIT, 701.80,OTHER, 470.85, 1073.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32883,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 180.04,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32884,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,SELFPAY,SELF PAY, 1352.63,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32885,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,SELFPAY,SELF PAY, 1352.63,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32886,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32887,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32888,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,SELFPAY,SELF PAY, 3070.71,,OUTPCT LIMIT, 2267.81,OTHER, 1127.76, 4012.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32889,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32890,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,SELFPAY,SELF PAY, 1089.08,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32891,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,SELFPAY,SELF PAY, 1089.08,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32892,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32893,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32894,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,SELFPAY,SELF PAY, 872.81,,OUTPCT LIMIT, 635.79,OTHER, 283.54, 1140.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32895,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 217.00,OTHER, 99.36, 283.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32896,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,SELFPAY,SELF PAY, 1401.62,,OUTPCT LIMIT, 984.09,OTHER, 300.36, 1831.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32897,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 223.01,OTHER, 99.36, 300.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32898,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,SELFPAY,SELF PAY, 1450.74,,OUTPCT LIMIT, 1050.06,OTHER, 443.12, 1895.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32899,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 274.00,OTHER, 99.36, 443.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32900,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,SELFPAY,SELF PAY, 780.00,,OUTPCT LIMIT, 684.67,OTHER, 447.20, 1019.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32901,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,SELFPAY,SELF PAY, 168.75,,OUTPCT LIMIT, 380.97,OTHER, 99.36, 742.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32902,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,SELFPAY,SELF PAY, 3573.00,,OUTPCT LIMIT, 2685.69,OTHER, 1509.32, 4668.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32903,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,SELFPAY,SELF PAY, 300.00,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32904,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,SELFPAY,SELF PAY, 3700.50,,OUTPCT LIMIT, 2768.70,OTHER, 1509.32, 4835.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32905,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,SELFPAY,SELF PAY, 300.00,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32906,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,SELFPAY,SELF PAY, 45.44,,OUTPCT LIMIT, 34.30,OTHER, 19.78, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32907,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,SELFPAY,SELF PAY, 45.44,,OUTPCT LIMIT, 32.49,OTHER, 12.18, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32908,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,SELFPAY,SELF PAY, 466.50,,OUTPCT LIMIT, 398.65,OTHER, 267.46, 609.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32909,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,SELFPAY,SELF PAY, 104.89,,OUTPCT LIMIT, 70.69,OTHER, 10.09, 137.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32910,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,SELFPAY,SELF PAY, 182.06,,OUTPCT LIMIT, 122.16,OTHER, 15.20, 237.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32911,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,SELFPAY,SELF PAY, 142.85,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32912,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,SELFPAY,SELF PAY, 142.85,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32913,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,SELFPAY,SELF PAY, 123.75,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32914,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,SELFPAY,SELF PAY, 123.75,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32915,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,SELFPAY,SELF PAY, 214.29,,OUTPCT LIMIT, 155.85,OTHER, 68.59, 280.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32916,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,SELFPAY,SELF PAY, 117.01,,OUTPCT LIMIT, 78.98,OTHER, 11.76, 152.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32917,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,SELFPAY,SELF PAY, 98.25,,OUTPCT LIMIT, 69.30,OTHER, 22.37, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32918,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,SELFPAY,SELF PAY, 335.25,,OUTPCT LIMIT, 229.30,OTHER, 46.28, 438.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32919,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,SELFPAY,SELF PAY, 132.20,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32920,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,SELFPAY,SELF PAY, 125.70,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32921,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,SELFPAY,SELF PAY, 75.01,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32922,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,SELFPAY,SELF PAY, 75.01,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32923,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,SELFPAY,SELF PAY, 116.00,,OUTPCT LIMIT, 80.17,OTHER, 19.50, 151.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32924,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,SELFPAY,SELF PAY, 72.47,,OUTPCT LIMIT, 54.61,OTHER, 31.20, 94.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32925,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,SELFPAY,SELF PAY, 115.94,,OUTPCT LIMIT, 80.03,OTHER, 19.08, 151.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32926,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,SELFPAY,SELF PAY, 114.62,,OUTPCT LIMIT, 79.17,OTHER, 19.08, 149.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32927,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,SELFPAY,SELF PAY, 94.74,,OUTPCT LIMIT, 63.95,OTHER, 9.52, 123.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32928,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,SELFPAY,SELF PAY, 35.25,,OUTPCT LIMIT, 28.28,OTHER, 20.21, 46.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32929,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,SELFPAY,SELF PAY, 121.56,,OUTPCT LIMIT, 83.69,OTHER, 19.08, 158.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32930,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,SELFPAY,SELF PAY, 74.06,,OUTPCT LIMIT, 53.47,OTHER, 22.03, 96.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32931,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,SELFPAY,SELF PAY, 115.61,,OUTPCT LIMIT, 79.81,OTHER, 19.08, 151.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32932,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,SELFPAY,SELF PAY, 61.34,,OUTPCT LIMIT, 44.64,OTHER, 19.78, 80.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32933,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,SELFPAY,SELF PAY, 216.88,,OUTPCT LIMIT, 145.91,OTHER, 19.78, 283.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32934,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,SELFPAY,SELF PAY, 92.03,,OUTPCT LIMIT, 64.76,OTHER, 20.36, 120.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32935,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,SELFPAY,SELF PAY, 180.09,,OUTPCT LIMIT, 121.34,OTHER, 17.16, 235.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32936,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,SELFPAY,SELF PAY, 123.05,,OUTPCT LIMIT, 84.76,OTHER, 19.50, 160.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32937,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,SELFPAY,SELF PAY, 194.98,,OUTPCT LIMIT, 134.69,OTHER, 32.53, 254.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32938,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,SELFPAY,SELF PAY, 129.81,,OUTPCT LIMIT, 90.91,OTHER, 26.84, 169.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32939,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,SELFPAY,SELF PAY, 142.76,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32940,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,SELFPAY,SELF PAY, 18.75,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32941,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,SELFPAY,SELF PAY, 30.00,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32942,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,SELFPAY,SELF PAY, 30.00,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32943,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,SELFPAY,SELF PAY, 196.41,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32944,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,SELFPAY,SELF PAY, 221.25,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32945,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,SELFPAY,SELF PAY, 126.75,,OUTPCT LIMIT, 108.31,OTHER, 72.67, 165.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32946,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,SELFPAY,SELF PAY, 112.50,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32947,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,SELFPAY,SELF PAY, 57.00,,OUTPCT LIMIT, 48.71,OTHER, 32.68, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32948,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,SELFPAY,SELF PAY, 210.58,,OUTPCT LIMIT, 179.95,OTHER, 120.73, 275.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32949,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,SELFPAY,SELF PAY, 134.14,,OUTPCT LIMIT, 114.63,OTHER, 76.91, 175.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32950,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,SELFPAY,SELF PAY, 30.62,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32951,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,SELFPAY,SELF PAY, 56.25,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32952,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,SELFPAY,SELF PAY, 30.62,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32953,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,SELFPAY,SELF PAY, 30.62,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32954,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,SELFPAY,SELF PAY, 105.75,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32955,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,SELFPAY,SELF PAY, 79.42,,OUTPCT LIMIT, 67.87,OTHER, 45.53, 103.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32956,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,SELFPAY,SELF PAY, 119.25,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32957,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,SELFPAY,SELF PAY, 119.25,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32958,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,SELFPAY,SELF PAY, 119.25,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32959,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,SELFPAY,SELF PAY, 101.25,,OUTPCT LIMIT, 86.52,OTHER, 58.05, 132.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32960,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,SELFPAY,SELF PAY, 64.50,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32961,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,SELFPAY,SELF PAY, 218.25,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32962,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,SELFPAY,SELF PAY, 51.91,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32963,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,SELFPAY,SELF PAY, 51.91,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32964,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,SELFPAY,SELF PAY, 51.91,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32965,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,SELFPAY,SELF PAY, 30.97,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32966,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,SELFPAY,SELF PAY, 30.97,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32967,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,SELFPAY,SELF PAY, 30.97,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32968,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,SELFPAY,SELF PAY, 9.75,,OUTPCT LIMIT, 7.12,OTHER, 3.24, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32969,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,SELFPAY,SELF PAY, 11.25,,OUTPCT LIMIT, 8.07,OTHER, 3.12, 14.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32970,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,SELFPAY,SELF PAY, 47.48,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32971,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,SELFPAY,SELF PAY, 47.48,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32972,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,SELFPAY,SELF PAY, 111.75,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32973,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,SELFPAY,SELF PAY, 111.75,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32974,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,SELFPAY,SELF PAY, 184.98,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32975,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,SELFPAY,SELF PAY, 184.98,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32976,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,SELFPAY,SELF PAY, 369.00,,OUTPCT LIMIT, 262.66,OTHER, 94.12, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32977,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,SELFPAY,SELF PAY, 610.61,,OUTPCT LIMIT, 428.98,OTHER, 131.99, 797.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32978,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,SELFPAY,SELF PAY, 151.76,,OUTPCT LIMIT, 129.68,OTHER, 87.01, 198.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32979,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,SELFPAY,SELF PAY, 286.50,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32980,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,SELFPAY,SELF PAY, 286.50,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32981,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,SELFPAY,SELF PAY, 79.25,,OUTPCT LIMIT, 53.15,OTHER, 6.50, 103.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32982,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,SELFPAY,SELF PAY, 55.46,,OUTPCT LIMIT, 38.90,OTHER, 11.76, 72.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32983,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,SELFPAY,SELF PAY, 205.19,,OUTPCT LIMIT, 146.83,OTHER, 55.61, 268.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32984,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,SELFPAY,SELF PAY, 28.31,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32985,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,SELFPAY,SELF PAY, 28.31,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32986,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,SELFPAY,SELF PAY, 40.31,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32987,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,SELFPAY,SELF PAY, 40.31,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32988,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,SELFPAY,SELF PAY, 90.00,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32989,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,SELFPAY,SELF PAY, 90.00,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32990,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,SELFPAY,SELF PAY, 73.03,,OUTPCT LIMIT, 50.88,OTHER, 13.98, 95.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32991,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,SELFPAY,SELF PAY, 102.07,,OUTPCT LIMIT, 71.06,OTHER, 19.36, 133.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32992,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,SELFPAY,SELF PAY, 161.12,,OUTPCT LIMIT, 109.86,OTHER, 20.82, 210.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32993,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,SELFPAY,SELF PAY, 114.29,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32994,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,SELFPAY,SELF PAY, 114.29,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32995,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,SELFPAY,SELF PAY, 89.25,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32996,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,SELFPAY,SELF PAY, 89.25,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32997,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,SELFPAY,SELF PAY, 74.60,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32998,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,SELFPAY,SELF PAY, 74.60,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 32999,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,SELFPAY,SELF PAY, 138.75,,OUTPCT LIMIT, 100.38,OTHER, 42.16, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33000,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,SELFPAY,SELF PAY, 170.32,,OUTPCT LIMIT, 121.92,OTHER, 46.34, 222.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33001,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,SELFPAY,SELF PAY, 66.00,,OUTPCT LIMIT, 50.20,OTHER, 30.37, 86.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33002,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,SELFPAY,SELF PAY, 168.66,,OUTPCT LIMIT, 116.31,OTHER, 27.31, 220.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33003,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,SELFPAY,SELF PAY, 71.25,,OUTPCT LIMIT, 49.78,OTHER, 14.24, 93.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33004,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,SELFPAY,SELF PAY, 88.92,,OUTPCT LIMIT, 63.44,OTHER, 23.30, 116.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33005,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,SELFPAY,SELF PAY, 53.21,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33006,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,SELFPAY,SELF PAY, 53.21,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33007,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,SELFPAY,SELF PAY, 48.15,,OUTPCT LIMIT, 33.07,OTHER, 7.22, 62.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33008,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,SELFPAY,SELF PAY, 27.38,,OUTPCT LIMIT, 19.33,OTHER, 6.31, 35.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33009,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,SELFPAY,SELF PAY, 48.88,,OUTPCT LIMIT, 33.34,OTHER, 6.38, 63.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33010,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 56.73,OTHER, 22.92, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33011,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,SELFPAY,SELF PAY, 175.08,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33012,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,SELFPAY,SELF PAY, 186.75,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33013,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,SELFPAY,SELF PAY, 175.08,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33014,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,SELFPAY,SELF PAY, 175.82,,OUTPCT LIMIT, 123.66,OTHER, 38.58, 229.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33015,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,SELFPAY,SELF PAY, 49.63,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33016,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,SELFPAY,SELF PAY, 49.63,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33017,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,SELFPAY,SELF PAY, 49.63,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33018,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,SELFPAY,SELF PAY, 99.14,,OUTPCT LIMIT, 69.24,OTHER, 19.70, 129.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33019,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,SELFPAY,SELF PAY, 73.57,,OUTPCT LIMIT, 49.97,OTHER, 8.69, 96.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33020,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,SELFPAY,SELF PAY, 61.50,,OUTPCT LIMIT, 44.47,OTHER, 18.58, 80.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33021,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,SELFPAY,SELF PAY, 93.56,,OUTPCT LIMIT, 65.14,OTHER, 17.74, 122.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33022,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,SELFPAY,SELF PAY, 124.02,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33023,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,SELFPAY,SELF PAY, 124.02,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33024,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,SELFPAY,SELF PAY, 81.75,,OUTPCT LIMIT, 59.01,OTHER, 24.29, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33025,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,SELFPAY,SELF PAY, 182.33,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33026,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,SELFPAY,SELF PAY, 184.07,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33027,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,SELFPAY,SELF PAY, 81.05,,OUTPCT LIMIT, 56.46,OTHER, 15.47, 105.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33028,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,SELFPAY,SELF PAY, 18.00,,OUTPCT LIMIT, 13.69,OTHER, 8.28, 23.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33029,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,SELFPAY,SELF PAY, 106.68,,OUTPCT LIMIT, 73.71,OTHER, 17.87, 139.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33030,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,SELFPAY,SELF PAY, 125.95,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33031,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,SELFPAY,SELF PAY, 125.95,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33032,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,SELFPAY,SELF PAY, 93.26,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33033,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,SELFPAY,SELF PAY, 93.26,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33034,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,SELFPAY,SELF PAY, 279.42,,OUTPCT LIMIT, 190.19,OTHER, 34.69, 365.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33035,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,SELFPAY,SELF PAY, 316.02,,OUTPCT LIMIT, 214.01,OTHER, 34.69, 412.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33036,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,SELFPAY,SELF PAY, 69.51,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33037,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,SELFPAY,SELF PAY, 69.51,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33038,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,SELFPAY,SELF PAY, 57.00,,OUTPCT LIMIT, 41.70,OTHER, 19.28, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33039,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,SELFPAY,SELF PAY, 85.65,,OUTPCT LIMIT, 59.73,OTHER, 16.63, 111.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33040,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,SELFPAY,SELF PAY, 45.88,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33041,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,SELFPAY,SELF PAY, 45.88,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33042,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,SELFPAY,SELF PAY, 45.88,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33043,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,SELFPAY,SELF PAY, 57.35,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33044,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,SELFPAY,SELF PAY, 57.35,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33045,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,SELFPAY,SELF PAY, 138.58,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33046,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,SELFPAY,SELF PAY, 138.58,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33047,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,SELFPAY,SELF PAY, 63.00,,OUTPCT LIMIT, 45.06,OTHER, 16.97, 82.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33048,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,SELFPAY,SELF PAY, 113.65,,OUTPCT LIMIT, 76.21,OTHER, 9.31, 148.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33049,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,SELFPAY,SELF PAY, 103.00,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33050,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,SELFPAY,SELF PAY, 103.00,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33051,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,SELFPAY,SELF PAY, 106.00,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33052,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,SELFPAY,SELF PAY, 106.00,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33053,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,SELFPAY,SELF PAY, 182.40,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33054,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,SELFPAY,SELF PAY, 182.40,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33055,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,SELFPAY,SELF PAY, 134.28,,OUTPCT LIMIT, 93.87,OTHER, 27.06, 175.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33056,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,SELFPAY,SELF PAY, 193.38,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33057,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,SELFPAY,SELF PAY, 193.38,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33058,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,SELFPAY,SELF PAY, 111.75,,OUTPCT LIMIT, 83.83,OTHER, 46.51, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33059,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,SELFPAY,SELF PAY, 100.50,,OUTPCT LIMIT, 73.72,OTHER, 34.82, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33060,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,SELFPAY,SELF PAY, 102.75,,OUTPCT LIMIT, 75.45,OTHER, 35.93, 134.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33061,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,SELFPAY,SELF PAY, 174.56,,OUTPCT LIMIT, 121.64,OTHER, 33.53, 228.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33062,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,SELFPAY,SELF PAY, 103.55,,OUTPCT LIMIT, 69.17,OTHER, 7.34, 135.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33063,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,SELFPAY,SELF PAY, 182.63,,OUTPCT LIMIT, 124.67,OTHER, 24.19, 238.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33064,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,SELFPAY,SELF PAY, 110.25,,OUTPCT LIMIT, 76.46,OTHER, 19.63, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33065,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,SELFPAY,SELF PAY, 102.05,,OUTPCT LIMIT, 71.48,OTHER, 21.17, 133.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33066,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,SELFPAY,SELF PAY, 317.82,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33067,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,SELFPAY,SELF PAY, 116.26,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33068,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,SELFPAY,SELF PAY, 79.32,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33069,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,SELFPAY,SELF PAY, 79.32,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33070,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,SELFPAY,SELF PAY, 79.32,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33071,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,SELFPAY,SELF PAY, 91.10,,OUTPCT LIMIT, 64.96,OTHER, 23.70, 119.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33072,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,SELFPAY,SELF PAY, 49.50,,OUTPCT LIMIT, 34.98,OTHER, 11.54, 64.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33073,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,SELFPAY,SELF PAY, 298.86,,OUTPCT LIMIT, 203.52,OTHER, 37.54, 390.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33074,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,SELFPAY,SELF PAY, 85.50,,OUTPCT LIMIT, 61.71,OTHER, 25.39, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33075,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,SELFPAY,SELF PAY, 37.31,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33076,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,SELFPAY,SELF PAY, 37.31,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33077,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,SELFPAY,SELF PAY, 37.31,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33078,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,SELFPAY,SELF PAY, 41.42,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33079,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,SELFPAY,SELF PAY, 41.42,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33080,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,SELFPAY,SELF PAY, 41.42,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33081,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,SELFPAY,SELF PAY, 19.65,,OUTPCT LIMIT, 14.14,OTHER, 5.66, 25.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33082,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,SELFPAY,SELF PAY, 96.50,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33083,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,SELFPAY,SELF PAY, 96.50,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33084,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,SELFPAY,SELF PAY, 83.84,,OUTPCT LIMIT, 57.91,OTHER, 13.97, 109.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33085,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,SELFPAY,SELF PAY, 53.87,,OUTPCT LIMIT, 37.55,OTHER, 10.37, 70.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33086,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,SELFPAY,SELF PAY, 135.71,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33087,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,SELFPAY,SELF PAY, 135.71,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33088,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,SELFPAY,SELF PAY, 135.42,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33089,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,SELFPAY,SELF PAY, 135.42,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33090,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,SELFPAY,SELF PAY, 96.35,,OUTPCT LIMIT, 67.05,OTHER, 18.12, 125.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33091,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,SELFPAY,SELF PAY, 103.50,,OUTPCT LIMIT, 74.92,OTHER, 31.62, 135.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33092,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,SELFPAY,SELF PAY, 69.08,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33093,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,SELFPAY,SELF PAY, 69.08,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33094,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,SELFPAY,SELF PAY, 69.08,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33095,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,SELFPAY,SELF PAY, 143.90,,OUTPCT LIMIT, 99.83,OTHER, 25.80, 188.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33096,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,SELFPAY,SELF PAY, 225.75,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33097,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,SELFPAY,SELF PAY, 199.04,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33098,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,SELFPAY,SELF PAY, 199.04,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33099,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,SELFPAY,SELF PAY, 199.04,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33100,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,SELFPAY,SELF PAY, 199.04,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33101,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,SELFPAY,SELF PAY, 199.04,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33102,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,SELFPAY,SELF PAY, 222.46,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33103,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,SELFPAY,SELF PAY, 134.30,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33104,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,SELFPAY,SELF PAY, 207.07,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33105,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,SELFPAY,SELF PAY, 32.25,,OUTPCT LIMIT, 25.93,OTHER, 18.49, 42.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33106,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,SELFPAY,SELF PAY, 100.02,,OUTPCT LIMIT, 69.04,OTHER, 16.46, 130.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33107,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,SELFPAY,SELF PAY, 63.99,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33108,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,SELFPAY,SELF PAY, 63.99,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33109,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,SELFPAY,SELF PAY, 63.99,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33110,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,SELFPAY,SELF PAY, 78.30,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33111,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,SELFPAY,SELF PAY, 78.30,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33112,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,SELFPAY,SELF PAY, 78.30,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33113,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,SELFPAY,SELF PAY, 78.30,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33114,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,SELFPAY,SELF PAY, 101.48,,OUTPCT LIMIT, 70.04,OTHER, 16.66, 132.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33115,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,SELFPAY,SELF PAY, 64.85,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33116,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,SELFPAY,SELF PAY, 85.44,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33117,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,SELFPAY,SELF PAY, 124.50,,OUTPCT LIMIT, 85.45,OTHER, 18.42, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33118,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,SELFPAY,SELF PAY, 95.25,,OUTPCT LIMIT, 68.77,OTHER, 28.37, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33119,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,SELFPAY,SELF PAY, 77.74,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33120,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,SELFPAY,SELF PAY, 77.74,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33121,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,SELFPAY,SELF PAY, 89.26,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33122,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,SELFPAY,SELF PAY, 89.26,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33123,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,SELFPAY,SELF PAY, 204.54,,OUTPCT LIMIT, 149.05,OTHER, 66.68, 267.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33124,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,SELFPAY,SELF PAY, 48.75,,OUTPCT LIMIT, 43.46,OTHER, 27.95, 63.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33125,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,SELFPAY,SELF PAY, 60.53,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33126,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,SELFPAY,SELF PAY, 60.53,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33127,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,SELFPAY,SELF PAY, 58.89,,OUTPCT LIMIT, 40.64,OTHER, 9.65, 76.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33128,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,SELFPAY,SELF PAY, 300.68,,OUTPCT LIMIT, 204.04,OTHER, 34.72, 392.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33129,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,SELFPAY,SELF PAY, 79.74,,OUTPCT LIMIT, 57.49,OTHER, 23.41, 104.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33130,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,SELFPAY,SELF PAY, 236.15,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33131,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,SELFPAY,SELF PAY, 236.15,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33132,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,SELFPAY,SELF PAY, 125.00,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33133,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,SELFPAY,SELF PAY, 91.14,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33134,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,SELFPAY,SELF PAY, 164.25,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33135,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,SELFPAY,SELF PAY, 164.25,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33136,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,SELFPAY,SELF PAY, 159.25,,OUTPCT LIMIT, 110.95,OTHER, 30.54, 208.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33137,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,SELFPAY,SELF PAY, 79.72,,OUTPCT LIMIT, 54.17,OTHER, 9.52, 104.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33138,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,SELFPAY,SELF PAY, 64.68,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33139,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,SELFPAY,SELF PAY, 64.68,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33140,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,SELFPAY,SELF PAY, 124.70,,OUTPCT LIMIT, 86.15,OTHER, 20.81, 162.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33141,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,SELFPAY,SELF PAY, 204.04,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33142,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,SELFPAY,SELF PAY, 204.04,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33143,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,SELFPAY,SELF PAY, 57.00,,OUTPCT LIMIT, 43.75,OTHER, 27.89, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33144,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,SELFPAY,SELF PAY, 276.28,,OUTPCT LIMIT, 186.61,OTHER, 28.27, 361.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33145,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,SELFPAY,SELF PAY, 64.50,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33146,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,SELFPAY,SELF PAY, 70.95,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33147,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,SELFPAY,SELF PAY, 51.56,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33148,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,SELFPAY,SELF PAY, 51.56,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33149,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,SELFPAY,SELF PAY, 41.84,,OUTPCT LIMIT, 28.87,OTHER, 6.85, 54.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33150,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,SELFPAY,SELF PAY, 18.75,,OUTPCT LIMIT, 13.83,OTHER, 6.82, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33151,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,SELFPAY,SELF PAY, 62.30,,OUTPCT LIMIT, 45.56,OTHER, 21.01, 81.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33152,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,SELFPAY,SELF PAY, 131.43,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33153,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,SELFPAY,SELF PAY, 131.43,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33154,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,SELFPAY,SELF PAY, 143.55,,OUTPCT LIMIT, 102.79,OTHER, 39.19, 187.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33155,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,SELFPAY,SELF PAY, 139.04,,OUTPCT LIMIT, 97.17,OTHER, 27.91, 181.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33156,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,SELFPAY,SELF PAY, 123.98,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33157,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,SELFPAY,SELF PAY, 133.76,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33158,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,SELFPAY,SELF PAY, 133.76,,OUTPCT LIMIT, 93.39,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33159,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,SELFPAY,SELF PAY, 35.94,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33160,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,SELFPAY,SELF PAY, 35.94,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33161,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,SELFPAY,SELF PAY, 86.90,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33162,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,SELFPAY,SELF PAY, 86.90,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33163,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,SELFPAY,SELF PAY, 86.90,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33164,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,SELFPAY,SELF PAY, 61.35,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33165,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,SELFPAY,SELF PAY, 61.35,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33166,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,SELFPAY,SELF PAY, 64.07,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33167,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,SELFPAY,SELF PAY, 298.57,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33168,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,SELFPAY,SELF PAY, 132.65,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33169,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,SELFPAY,SELF PAY, 114.39,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33170,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,SELFPAY,SELF PAY, 301.78,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33171,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,SELFPAY,SELF PAY, 195.36,,OUTPCT LIMIT, 136.35,OTHER, 38.44, 255.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33172,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,SELFPAY,SELF PAY, 143.82,,OUTPCT LIMIT, 103.27,OTHER, 40.46, 187.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33173,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,SELFPAY,SELF PAY, 106.50,,OUTPCT LIMIT, 76.88,OTHER, 31.67, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33174,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,SELFPAY,SELF PAY, 264.00,,OUTPCT LIMIT, 178.83,OTHER, 29.15, 344.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33175,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,SELFPAY,SELF PAY, 124.37,,OUTPCT LIMIT, 88.43,OTHER, 31.30, 162.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33176,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,SELFPAY,SELF PAY, 43.58,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33177,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,SELFPAY,SELF PAY, 43.58,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33178,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,SELFPAY,SELF PAY, 67.78,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33179,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,SELFPAY,SELF PAY, 67.78,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33180,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,SELFPAY,SELF PAY, 13.91,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33181,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,SELFPAY,SELF PAY, 266.38,,OUTPCT LIMIT, 180.72,OTHER, 30.61, 348.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33182,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,SELFPAY,SELF PAY, 461.04,,OUTPCT LIMIT, 302.95,OTHER, 11.66, 602.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33183,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,SELFPAY,SELF PAY, 112.37,,OUTPCT LIMIT, 81.90,OTHER, 36.67, 146.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33184,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,SELFPAY,SELF PAY, 175.52,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33185,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,SELFPAY,SELF PAY, 175.52,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33186,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,SELFPAY,SELF PAY, 175.52,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33187,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,SELFPAY,SELF PAY, 175.52,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33188,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,SELFPAY,SELF PAY, 122.13,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33189,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,SELFPAY,SELF PAY, 122.13,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33190,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,SELFPAY,SELF PAY, 156.43,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33191,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,SELFPAY,SELF PAY, 156.43,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33192,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,SELFPAY,SELF PAY, 78.20,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33193,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,SELFPAY,SELF PAY, 78.20,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33194,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,SELFPAY,SELF PAY, 111.90,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33195,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,SELFPAY,SELF PAY, 111.90,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33196,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,SELFPAY,SELF PAY, 111.90,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33197,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,SELFPAY,SELF PAY, 72.00,,OUTPCT LIMIT, 51.95,OTHER, 21.29, 94.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33198,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,SELFPAY,SELF PAY, 104.09,,OUTPCT LIMIT, 73.53,OTHER, 24.19, 136.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33199,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,SELFPAY,SELF PAY, 210.00,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33200,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,SELFPAY,SELF PAY, 210.00,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33201,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,SELFPAY,SELF PAY, 69.00,,OUTPCT LIMIT, 49.79,OTHER, 20.42, 90.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33202,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,SELFPAY,SELF PAY, 56.12,,OUTPCT LIMIT, 38.32,OTHER, 7.46, 73.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33203,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,SELFPAY,SELF PAY, 52.49,,OUTPCT LIMIT, 35.99,OTHER, 7.63, 68.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33204,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,SELFPAY,SELF PAY, 83.15,,OUTPCT LIMIT, 58.51,OTHER, 18.37, 108.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33205,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,SELFPAY,SELF PAY, 57.08,,OUTPCT LIMIT, 39.13,OTHER, 8.27, 74.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33206,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,SELFPAY,SELF PAY, 114.50,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33207,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,SELFPAY,SELF PAY, 114.50,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33208,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,SELFPAY,SELF PAY, 112.26,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33209,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,SELFPAY,SELF PAY, 112.26,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33210,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,SELFPAY,SELF PAY, 186.59,,OUTPCT LIMIT, 126.89,OTHER, 22.69, 243.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33211,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,SELFPAY,SELF PAY, 120.90,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33212,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,SELFPAY,SELF PAY, 120.90,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33213,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,SELFPAY,SELF PAY, 58.01,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33214,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,SELFPAY,SELF PAY, 58.01,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33215,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,SELFPAY,SELF PAY, 58.01,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33216,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,SELFPAY,SELF PAY, 31.79,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33217,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,SELFPAY,SELF PAY, 31.79,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33218,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,SELFPAY,SELF PAY, 46.58,,OUTPCT LIMIT, 31.87,OTHER, 6.50, 60.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33219,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,SELFPAY,SELF PAY, 57.38,,OUTPCT LIMIT, 39.10,OTHER, 7.32, 74.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33220,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,SELFPAY,SELF PAY, 111.13,,OUTPCT LIMIT, 76.33,OTHER, 16.72, 145.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33221,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,SELFPAY,SELF PAY, 152.06,,OUTPCT LIMIT, 103.71,OTHER, 19.75, 198.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33222,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,SELFPAY,SELF PAY, 81.06,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33223,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,SELFPAY,SELF PAY, 81.06,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33224,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,SELFPAY,SELF PAY, 81.06,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33225,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,SELFPAY,SELF PAY, 120.53,,OUTPCT LIMIT, 85.61,OTHER, 29.96, 157.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33226,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,SELFPAY,SELF PAY, 141.11,,OUTPCT LIMIT, 97.04,OTHER, 21.67, 184.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33227,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,SELFPAY,SELF PAY, 63.32,,OUTPCT LIMIT, 42.88,OTHER, 6.94, 82.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33228,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,SELFPAY,SELF PAY, 65.27,,OUTPCT LIMIT, 43.80,OTHER, 5.47, 85.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33229,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,SELFPAY,SELF PAY, 26.17,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33230,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,SELFPAY,SELF PAY, 26.17,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33231,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,SELFPAY,SELF PAY, 31.71,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33232,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,SELFPAY,SELF PAY, 31.71,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33233,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33234,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,SELFPAY,SELF PAY, 64.43,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33235,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,SELFPAY,SELF PAY, 65.27,,OUTPCT LIMIT, 44.71,OTHER, 9.31, 85.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33236,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,SELFPAY,SELF PAY, 55.73,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33237,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,SELFPAY,SELF PAY, 55.73,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33238,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,SELFPAY,SELF PAY, 29.25,,OUTPCT LIMIT, 19.92,OTHER, 3.66, 38.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33239,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,SELFPAY,SELF PAY, 47.75,,OUTPCT LIMIT, 32.63,OTHER, 6.46, 62.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33240,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,SELFPAY,SELF PAY, 139.21,,OUTPCT LIMIT, 96.77,OTHER, 25.78, 181.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33241,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,SELFPAY,SELF PAY, 186.52,,OUTPCT LIMIT, 129.31,OTHER, 33.04, 243.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33242,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,SELFPAY,SELF PAY, 194.25,,OUTPCT LIMIT, 130.54,OTHER, 17.06, 253.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33243,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,SELFPAY,SELF PAY, 143.75,,OUTPCT LIMIT, 98.34,OTHER, 19.93, 187.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33244,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,SELFPAY,SELF PAY, 128.63,,OUTPCT LIMIT, 89.00,OTHER, 22.06, 168.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33245,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,SELFPAY,SELF PAY, 145.50,,OUTPCT LIMIT, 98.22,OTHER, 14.66, 190.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33246,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,SELFPAY,SELF PAY, 78.80,,OUTPCT LIMIT, 54.63,OTHER, 13.99, 102.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33247,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,SELFPAY,SELF PAY, 98.25,,OUTPCT LIMIT, 70.40,OTHER, 27.00, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33248,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,SELFPAY,SELF PAY, 43.70,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33249,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,SELFPAY,SELF PAY, 43.41,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33250,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,SELFPAY,SELF PAY, 43.70,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33251,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,SELFPAY,SELF PAY, 19.50,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33252,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,SELFPAY,SELF PAY, 19.50,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33253,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,SELFPAY,SELF PAY, 19.50,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33254,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,SELFPAY,SELF PAY, 19.50,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33255,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,SELFPAY,SELF PAY, 61.65,,OUTPCT LIMIT, 41.60,OTHER, 6.14, 80.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33256,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,SELFPAY,SELF PAY, 39.00,,OUTPCT LIMIT, 26.32,OTHER, 3.89, 50.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33257,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,SELFPAY,SELF PAY, 52.93,,OUTPCT LIMIT, 36.35,OTHER, 7.93, 69.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33258,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,SELFPAY,SELF PAY, 127.50,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33259,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,SELFPAY,SELF PAY, 56.16,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33260,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,SELFPAY,SELF PAY, 113.64,,OUTPCT LIMIT, 76.67,OTHER, 11.26, 148.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33261,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,SELFPAY,SELF PAY, 891.26,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33262,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,SELFPAY,SELF PAY, 242.25,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33263,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33264,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33265,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33266,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33267,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33268,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33269,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33270,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33271,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33272,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33273,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33274,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33275,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33276,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33277,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33278,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33279,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33280,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33281,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33282,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33283,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33284,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33285,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33286,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33287,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33288,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33289,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33290,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33291,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33292,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33293,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33294,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33295,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33296,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33297,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33298,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33299,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,SELFPAY,SELF PAY, 46.23,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33300,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33301,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33302,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33303,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33304,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,SELFPAY,SELF PAY, 24.08,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33305,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33306,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33307,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33308,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33309,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33310,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33311,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33312,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33313,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33314,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33315,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33316,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33317,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33318,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33319,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33320,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33321,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33322,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,SELFPAY,SELF PAY, 50.01,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33323,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,SELFPAY,SELF PAY, 281.06,,OUTPCT LIMIT, 189.29,OTHER, 26.45, 367.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33324,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,SELFPAY,SELF PAY, 171.61,,OUTPCT LIMIT, 115.17,OTHER, 14.46, 224.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33325,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,SELFPAY,SELF PAY, 99.98,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33326,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,SELFPAY,SELF PAY, 168.96,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33327,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,SELFPAY,SELF PAY, 69.25,,OUTPCT LIMIT, 48.91,OTHER, 16.07, 90.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33328,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,SELFPAY,SELF PAY, 65.63,,OUTPCT LIMIT, 45.23,OTHER, 10.51, 85.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33329,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,SELFPAY,SELF PAY, 23.51,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33330,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,SELFPAY,SELF PAY, 23.51,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33331,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,SELFPAY,SELF PAY, 84.19,,OUTPCT LIMIT, 59.25,OTHER, 18.65, 110.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33332,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,SELFPAY,SELF PAY, 130.94,,OUTPCT LIMIT, 93.98,OTHER, 36.65, 171.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33333,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,SELFPAY,SELF PAY, 197.59,,OUTPCT LIMIT, 137.37,OTHER, 36.65, 258.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33334,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,SELFPAY,SELF PAY, 112.05,,OUTPCT LIMIT, 78.46,OTHER, 23.14, 146.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33335,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,SELFPAY,SELF PAY, 97.70,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33336,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,SELFPAY,SELF PAY, 97.45,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33337,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,SELFPAY,SELF PAY, 108.62,,OUTPCT LIMIT, 77.69,OTHER, 29.26, 141.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33338,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,SELFPAY,SELF PAY, 90.23,,OUTPCT LIMIT, 63.19,OTHER, 18.65, 117.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33339,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,SELFPAY,SELF PAY, 90.10,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33340,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,SELFPAY,SELF PAY, 97.81,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33341,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,SELFPAY,SELF PAY, 106.09,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33342,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,SELFPAY,SELF PAY, 106.09,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33343,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,SELFPAY,SELF PAY, 106.09,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33344,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,SELFPAY,SELF PAY, 106.09,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33345,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,SELFPAY,SELF PAY, 106.22,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33346,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,SELFPAY,SELF PAY, 106.09,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33347,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,SELFPAY,SELF PAY, 90.64,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33348,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,SELFPAY,SELF PAY, 84.50,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33349,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,SELFPAY,SELF PAY, 119.25,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33350,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,SELFPAY,SELF PAY, 182.38,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33351,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,SELFPAY,SELF PAY, 176.06,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33352,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,SELFPAY,SELF PAY, 18.75,,OUTPCT LIMIT, 15.65,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33353,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,SELFPAY,SELF PAY, 111.78,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33354,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,SELFPAY,SELF PAY, 114.93,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33355,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,SELFPAY,SELF PAY, 119.78,,OUTPCT LIMIT, 85.12,OTHER, 29.96, 156.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33356,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,SELFPAY,SELF PAY, 147.93,,OUTPCT LIMIT, 103.45,OTHER, 29.96, 193.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33357,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,SELFPAY,SELF PAY, 101.48,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33358,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,SELFPAY,SELF PAY, 264.38,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33359,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,SELFPAY,SELF PAY, 74.90,,OUTPCT LIMIT, 50.54,OTHER, 7.46, 97.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33360,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,SELFPAY,SELF PAY, 124.73,,OUTPCT LIMIT, 88.87,OTHER, 32.17, 162.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33361,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,SELFPAY,SELF PAY, 90.75,,OUTPCT LIMIT, 66.43,OTHER, 30.83, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33362,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,SELFPAY,SELF PAY, 80.26,,OUTPCT LIMIT, 57.43,OTHER, 21.72, 104.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33363,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,SELFPAY,SELF PAY, 394.69,,OUTPCT LIMIT, 265.06,OTHER, 33.95, 515.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33364,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,SELFPAY,SELF PAY, 110.25,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33365,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,SELFPAY,SELF PAY, 110.25,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33366,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,SELFPAY,SELF PAY, 151.88,,OUTPCT LIMIT, 111.82,OTHER, 54.34, 198.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33367,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,SELFPAY,SELF PAY, 245.93,,OUTPCT LIMIT, 176.22,OTHER, 67.64, 321.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33368,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,SELFPAY,SELF PAY, 121.13,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33369,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,SELFPAY,SELF PAY, 121.13,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33370,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,SELFPAY,SELF PAY, 100.50,,OUTPCT LIMIT, 68.73,OTHER, 13.84, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33371,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,SELFPAY,SELF PAY, 122.34,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33372,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,SELFPAY,SELF PAY, 157.50,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33373,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,SELFPAY,SELF PAY, 100.50,,OUTPCT LIMIT, 70.10,OTHER, 19.60, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33374,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,SELFPAY,SELF PAY, 68.99,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33375,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,SELFPAY,SELF PAY, 68.99,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33376,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,SELFPAY,SELF PAY, 261.75,,OUTPCT LIMIT, 191.67,OTHER, 89.24, 342.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33377,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,SELFPAY,SELF PAY, 14.03,,OUTPCT LIMIT, 12.31,OTHER, 8.04, 18.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33378,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,SELFPAY,SELF PAY, 26.18,,OUTPCT LIMIT, 18.56,OTHER, 6.34, 34.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33379,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,SELFPAY,SELF PAY, 47.69,,OUTPCT LIMIT, 36.21,OTHER, 21.67, 62.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33380,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,SELFPAY,SELF PAY, 79.50,,OUTPCT LIMIT, 55.25,OTHER, 14.66, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33381,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,SELFPAY,SELF PAY, 54.84,,OUTPCT LIMIT, 40.13,OTHER, 18.58, 71.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33382,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,SELFPAY,SELF PAY, 95.25,,OUTPCT LIMIT, 66.54,OTHER, 19.00, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33383,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,SELFPAY,SELF PAY, 126.77,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33384,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,SELFPAY,SELF PAY, 126.77,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33385,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,SELFPAY,SELF PAY, 126.77,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33386,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,SELFPAY,SELF PAY, 34.76,,OUTPCT LIMIT, 26.75,OTHER, 17.29, 45.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33387,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,SELFPAY,SELF PAY, 72.70,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33388,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,SELFPAY,SELF PAY, 195.00,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33389,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,SELFPAY,SELF PAY, 70.50,,OUTPCT LIMIT, 50.83,OTHER, 20.72, 92.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33390,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,SELFPAY,SELF PAY, 81.75,,OUTPCT LIMIT, 59.00,OTHER, 24.26, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33391,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,SELFPAY,SELF PAY, 90.95,,OUTPCT LIMIT, 64.46,OTHER, 22.02, 118.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33392,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,SELFPAY,SELF PAY, 81.83,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33393,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,SELFPAY,SELF PAY, 81.83,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33394,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,SELFPAY,SELF PAY, 137.24,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33395,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,SELFPAY,SELF PAY, 82.60,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33396,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,SELFPAY,SELF PAY, 82.60,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33397,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,SELFPAY,SELF PAY, 92.25,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33398,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,SELFPAY,SELF PAY, 92.25,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33399,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,SELFPAY,SELF PAY, 59.25,,OUTPCT LIMIT, 43.51,OTHER, 20.72, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33400,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,SELFPAY,SELF PAY, 66.29,,OUTPCT LIMIT, 47.68,OTHER, 19.00, 86.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33401,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,SELFPAY,SELF PAY, 79.50,,OUTPCT LIMIT, 58.39,OTHER, 27.86, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33402,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,SELFPAY,SELF PAY, 111.72,,OUTPCT LIMIT, 77.47,OTHER, 19.86, 145.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33403,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,SELFPAY,SELF PAY, 88.78,,OUTPCT LIMIT, 62.50,OTHER, 19.74, 116.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33404,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,SELFPAY,SELF PAY, 65.45,,OUTPCT LIMIT, 46.75,OTHER, 17.35, 85.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33405,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,SELFPAY,SELF PAY, 57.00,,OUTPCT LIMIT, 41.14,OTHER, 16.94, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33406,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,SELFPAY,SELF PAY, 97.37,,OUTPCT LIMIT, 67.08,OTHER, 15.47, 127.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33407,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,SELFPAY,SELF PAY, 71.08,,OUTPCT LIMIT, 50.52,OTHER, 17.84, 92.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33408,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,SELFPAY,SELF PAY, 37.35,,OUTPCT LIMIT, 28.18,OTHER, 16.21, 48.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33409,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,SELFPAY,SELF PAY, 73.83,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33410,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,SELFPAY,SELF PAY, 73.83,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33411,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,SELFPAY,SELF PAY, 56.25,,OUTPCT LIMIT, 41.16,OTHER, 19.07, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33412,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,SELFPAY,SELF PAY, 63.25,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33413,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,SELFPAY,SELF PAY, 63.25,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33414,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,SELFPAY,SELF PAY, 63.25,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33415,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,SELFPAY,SELF PAY, 65.44,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33416,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,SELFPAY,SELF PAY, 67.69,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33417,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,SELFPAY,SELF PAY, 67.69,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33418,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,SELFPAY,SELF PAY, 68.87,,OUTPCT LIMIT, 49.38,OTHER, 19.07, 89.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33419,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,SELFPAY,SELF PAY, 116.26,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33420,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,SELFPAY,SELF PAY, 116.26,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33421,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,SELFPAY,SELF PAY, 548.84,,OUTPCT LIMIT, 361.76,OTHER, 18.55, 717.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33422,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,SELFPAY,SELF PAY, 240.75,,OUTPCT LIMIT, 161.64,OTHER, 20.54, 314.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33423,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,SELFPAY,SELF PAY, 209.83,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33424,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,SELFPAY,SELF PAY, 209.83,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33425,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,SELFPAY,SELF PAY, 114.68,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33426,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,SELFPAY,SELF PAY, 114.68,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33427,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,SELFPAY,SELF PAY, 114.68,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33428,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,SELFPAY,SELF PAY, 179.25,,OUTPCT LIMIT, 152.44,OTHER, 102.77, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33429,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,SELFPAY,SELF PAY, 323.15,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33430,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,SELFPAY,SELF PAY, 323.15,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33431,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,SELFPAY,SELF PAY, 323.15,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33432,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,SELFPAY,SELF PAY, 122.75,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33433,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,SELFPAY,SELF PAY, 122.75,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33434,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,SELFPAY,SELF PAY, 122.75,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33435,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,SELFPAY,SELF PAY, 122.75,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33436,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,SELFPAY,SELF PAY, 122.75,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33437,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,SELFPAY,SELF PAY, 222.83,,OUTPCT LIMIT, 146.86,OTHER, 7.46, 291.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33438,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,SELFPAY,SELF PAY, 82.50,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33439,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,SELFPAY,SELF PAY, 82.50,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33440,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,SELFPAY,SELF PAY, 82.50,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33441,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,SELFPAY,SELF PAY, 68.31,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33442,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,SELFPAY,SELF PAY, 64.92,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33443,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,SELFPAY,SELF PAY, 68.31,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33444,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,SELFPAY,SELF PAY, 323.15,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33445,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,SELFPAY,SELF PAY, 323.15,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33446,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,SELFPAY,SELF PAY, 293.63,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33447,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,SELFPAY,SELF PAY, 104.63,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33448,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,SELFPAY,SELF PAY, 104.63,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33449,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,SELFPAY,SELF PAY, 445.67,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33450,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,SELFPAY,SELF PAY, 445.67,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33451,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,SELFPAY,SELF PAY, 445.67,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33452,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,SELFPAY,SELF PAY, 445.67,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33453,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,SELFPAY,SELF PAY, 445.67,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33454,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,SELFPAY,SELF PAY, 445.67,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33455,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,SELFPAY,SELF PAY, 104.63,,OUTPCT LIMIT, 76.50,OTHER, 35.20, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33456,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,SELFPAY,SELF PAY, 195.75,,OUTPCT LIMIT, 149.18,OTHER, 91.25, 255.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33457,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,SELFPAY,SELF PAY, 119.60,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33458,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,SELFPAY,SELF PAY, 119.60,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33459,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,SELFPAY,SELF PAY, 42.28,,OUTPCT LIMIT, 30.76,OTHER, 13.60, 55.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33460,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,SELFPAY,SELF PAY, 107.03,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33461,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,SELFPAY,SELF PAY, 107.03,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33462,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,SELFPAY,SELF PAY, 115.22,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33463,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,SELFPAY,SELF PAY, 115.22,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33464,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,SELFPAY,SELF PAY, 117.07,,OUTPCT LIMIT, 78.99,OTHER, 11.64, 152.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33465,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,SELFPAY,SELF PAY, 67.58,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33466,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,SELFPAY,SELF PAY, 67.58,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33467,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,SELFPAY,SELF PAY, 67.58,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33468,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,SELFPAY,SELF PAY, 59.42,,OUTPCT LIMIT, 40.96,OTHER, 9.55, 77.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33469,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,SELFPAY,SELF PAY, 64.37,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33470,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,SELFPAY,SELF PAY, 64.37,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33471,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,SELFPAY,SELF PAY, 64.37,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33472,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,SELFPAY,SELF PAY, 122.09,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33473,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,SELFPAY,SELF PAY, 122.09,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33474,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,SELFPAY,SELF PAY, 110.37,,OUTPCT LIMIT, 74.74,OTHER, 12.11, 144.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33475,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,SELFPAY,SELF PAY, 134.09,,OUTPCT LIMIT, 91.00,OTHER, 15.55, 175.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33476,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,SELFPAY,SELF PAY, 100.23,,OUTPCT LIMIT, 68.31,OTHER, 12.82, 130.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33477,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,SELFPAY,SELF PAY, 24.75,,OUTPCT LIMIT, 17.74,OTHER, 6.84, 32.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33478,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,SELFPAY,SELF PAY, 31.37,,OUTPCT LIMIT, 22.99,OTHER, 10.78, 40.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33479,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,SELFPAY,SELF PAY, 43.50,,OUTPCT LIMIT, 29.95,OTHER, 6.84, 56.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33480,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,SELFPAY,SELF PAY, 60.59,,OUTPCT LIMIT, 42.41,OTHER, 12.46, 79.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33481,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,SELFPAY,SELF PAY, 42.44,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33482,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,SELFPAY,SELF PAY, 39.52,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33483,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,SELFPAY,SELF PAY, 39.52,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33484,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,SELFPAY,SELF PAY, 39.67,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33485,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,SELFPAY,SELF PAY, 39.67,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33486,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,SELFPAY,SELF PAY, 55.75,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33487,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,SELFPAY,SELF PAY, 55.75,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33488,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,SELFPAY,SELF PAY, 40.39,,OUTPCT LIMIT, 28.29,OTHER, 8.38, 52.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33489,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,SELFPAY,SELF PAY, 95.25,,OUTPCT LIMIT, 68.72,OTHER, 28.16, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33490,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,SELFPAY,SELF PAY, 453.53,,OUTPCT LIMIT, 299.39,OTHER, 17.26, 592.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33491,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,SELFPAY,SELF PAY, 57.02,,OUTPCT LIMIT, 40.67,OTHER, 14.88, 74.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33492,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,SELFPAY,SELF PAY, 60.09,,OUTPCT LIMIT, 43.08,OTHER, 16.61, 78.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33493,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,SELFPAY,SELF PAY, 179.25,,OUTPCT LIMIT, 121.25,OTHER, 19.08, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33494,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,SELFPAY,SELF PAY, 95.25,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33495,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,SELFPAY,SELF PAY, 144.75,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33496,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,SELFPAY,SELF PAY, 144.76,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33497,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,SELFPAY,SELF PAY, 144.75,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33498,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,SELFPAY,SELF PAY, 144.75,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33499,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,SELFPAY,SELF PAY, 144.75,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33500,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,SELFPAY,SELF PAY, 282.86,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33501,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,SELFPAY,SELF PAY, 282.86,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33502,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,SELFPAY,SELF PAY, 117.85,,OUTPCT LIMIT, 100.71,OTHER, 67.57, 153.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33503,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,SELFPAY,SELF PAY, 317.60,,OUTPCT LIMIT, 221.47,OTHER, 61.69, 415.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33504,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,SELFPAY,SELF PAY, 98.92,,OUTPCT LIMIT, 76.43,OTHER, 50.53, 129.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33505,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,SELFPAY,SELF PAY, 362.25,,OUTPCT LIMIT, 265.03,OTHER, 122.54, 473.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33506,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,SELFPAY,SELF PAY, 144.76,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33507,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,SELFPAY,SELF PAY, 112.50,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33508,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,SELFPAY,SELF PAY, 112.50,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33509,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,SELFPAY,SELF PAY, 465.05,,OUTPCT LIMIT, 445.68,OTHER, 266.63, 607.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33510,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,SELFPAY,SELF PAY, 75.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33511,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,SELFPAY,SELF PAY, 75.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33512,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,SELFPAY,SELF PAY, 75.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33513,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,SELFPAY,SELF PAY, 279.47,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33514,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,SELFPAY,SELF PAY, 279.47,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33515,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33516,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,SELFPAY,SELF PAY, 248.25,,OUTPCT LIMIT, 173.66,OTHER, 50.53, 324.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33517,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,SELFPAY,SELF PAY, 95.25,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33518,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,SELFPAY,SELF PAY, 131.40,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33519,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,SELFPAY,SELF PAY, 458.96,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33520,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,SELFPAY,SELF PAY, 202.48,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33521,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,SELFPAY,SELF PAY, 202.48,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33522,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,SELFPAY,SELF PAY, 86.90,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33523,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,SELFPAY,SELF PAY, 86.90,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33524,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,SELFPAY,SELF PAY, 59.25,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33525,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,SELFPAY,SELF PAY, 59.25,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33526,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,SELFPAY,SELF PAY, 59.25,,OUTPCT LIMIT, 44.25,OTHER, 23.81, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33527,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,SELFPAY,SELF PAY, 18.75,,OUTPCT LIMIT, 17.88,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33528,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,SELFPAY,SELF PAY, 145.34,,OUTPCT LIMIT, 100.14,OTHER, 23.14, 189.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33529,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,SELFPAY,SELF PAY, 1094.25,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33530,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,SELFPAY,SELF PAY, 1094.25,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33531,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,SELFPAY,SELF PAY, 78.00,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33532,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,SELFPAY,SELF PAY, 78.00,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33533,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,SELFPAY,SELF PAY, 416.25,,OUTPCT LIMIT, 294.34,OTHER, 97.97, 543.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33534,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33535,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33536,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,SELFPAY,SELF PAY, 23.25,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33537,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,SELFPAY,SELF PAY, 23.25,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33538,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,SELFPAY,SELF PAY, 84.31,,OUTPCT LIMIT, 56.81,OTHER, 8.06, 110.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33539,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,SELFPAY,SELF PAY, 57.54,,OUTPCT LIMIT, 39.98,OTHER, 10.56, 75.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33540,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,SELFPAY,SELF PAY, 57.75,,OUTPCT LIMIT, 41.73,OTHER, 17.35, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33541,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,SELFPAY,SELF PAY, 4449.32,,OUTPCT LIMIT, 3802.17,OTHER, 2550.94, 5813.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33542,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,SELFPAY,SELF PAY, 84.50,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33543,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,SELFPAY,SELF PAY, 84.50,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33544,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,SELFPAY,SELF PAY, 22.13,,OUTPCT LIMIT, 23.30,OTHER, 12.69, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33545,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,SELFPAY,SELF PAY, 44.63,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33546,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,SELFPAY,SELF PAY, 22.31,,OUTPCT LIMIT, 23.42,OTHER, 12.79, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33547,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,SELFPAY,SELF PAY, 96.75,,OUTPCT LIMIT, 82.68,OTHER, 55.47, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33548,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33549,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,SELFPAY,SELF PAY, 114.75,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33550,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,SELFPAY,SELF PAY, 114.75,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33551,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,SELFPAY,SELF PAY, 104.21,,OUTPCT LIMIT, 89.06,OTHER, 59.75, 136.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33552,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,SELFPAY,SELF PAY, 37.50,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33553,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,SELFPAY,SELF PAY, 37.50,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33554,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,SELFPAY,SELF PAY, 445.04,,OUTPCT LIMIT, 356.50,OTHER, 255.16, 581.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33555,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,SELFPAY,SELF PAY, 929.84,,OUTPCT LIMIT, 687.64,OTHER, 345.38, 1214.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33556,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,SELFPAY,SELF PAY, 235.88,,OUTPCT LIMIT, 201.57,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33557,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33558,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33559,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,SELFPAY,SELF PAY, 63.75,,OUTPCT LIMIT, 60.00,OTHER, 36.55, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33560,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,SELFPAY,SELF PAY, 38.59,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33561,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,SELFPAY,SELF PAY, 38.59,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33562,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33563,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33564,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33565,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,SELFPAY,SELF PAY, 8.25,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33566,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,SELFPAY,SELF PAY, 8.25,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33567,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,SELFPAY,SELF PAY, 8.25,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33568,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,SELFPAY,SELF PAY, 8.25,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33569,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,SELFPAY,SELF PAY, 59.81,,OUTPCT LIMIT, 51.11,OTHER, 34.29, 78.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33570,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,SELFPAY,SELF PAY, 102.53,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33571,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,SELFPAY,SELF PAY, 102.53,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33572,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33573,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,SELFPAY,SELF PAY, 118.35,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33574,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,SELFPAY,SELF PAY, 118.35,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33575,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33576,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33577,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,SELFPAY,SELF PAY, 128.18,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33578,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,SELFPAY,SELF PAY, 128.18,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33579,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,SELFPAY,SELF PAY, 7.50,,OUTPCT LIMIT, 12.78,OTHER, 4.30, 33.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33580,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,SELFPAY,SELF PAY, 24.80,,OUTPCT LIMIT, 17.36,OTHER, 5.09, 32.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33581,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,SELFPAY,SELF PAY, 227.93,,OUTPCT LIMIT, 184.48,OTHER, 130.68, 297.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33582,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,SELFPAY,SELF PAY, 255.38,,OUTPCT LIMIT, 202.35,OTHER, 146.42, 333.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33583,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,SELFPAY,SELF PAY, 110.96,,OUTPCT LIMIT, 99.37,OTHER, 63.61, 144.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33584,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,SELFPAY,SELF PAY, 114.05,,OUTPCT LIMIT, 88.44,OTHER, 59.56, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33585,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,SELFPAY,SELF PAY, 146.90,,OUTPCT LIMIT, 131.72,OTHER, 84.22, 191.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33586,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,SELFPAY,SELF PAY, 144.43,,OUTPCT LIMIT, 117.05,OTHER, 82.81, 188.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33587,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,SELFPAY,SELF PAY, 220.67,,OUTPCT LIMIT, 179.75,OTHER, 126.51, 288.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33588,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,SELFPAY,SELF PAY, 190.91,,OUTPCT LIMIT, 158.52,OTHER, 109.46, 249.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33589,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,SELFPAY,SELF PAY, 230.59,,OUTPCT LIMIT, 186.21,OTHER, 132.20, 301.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33590,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,SELFPAY,SELF PAY, 110.33,,OUTPCT LIMIT, 83.96,OTHER, 50.93, 144.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33591,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,SELFPAY,SELF PAY, 177.90,,OUTPCT LIMIT, 167.44,OTHER, 102.00, 232.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33592,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,SELFPAY,SELF PAY, 185.33,,OUTPCT LIMIT, 172.28,OTHER, 106.26, 242.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33593,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,SELFPAY,SELF PAY, 44.63,,OUTPCT LIMIT, 49.86,OTHER, 25.59, 87.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33594,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,SELFPAY,SELF PAY, 185.96,,OUTPCT LIMIT, 141.43,OTHER, 85.51, 242.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33595,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,SELFPAY,SELF PAY, 79.22,,OUTPCT LIMIT, 69.71,OTHER, 45.42, 103.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33596,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,SELFPAY,SELF PAY, 210.13,,OUTPCT LIMIT, 177.65,OTHER, 120.47, 274.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33597,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,SELFPAY,SELF PAY, 228.26,,OUTPCT LIMIT, 189.46,OTHER, 130.87, 298.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33598,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,SELFPAY,SELF PAY, 367.22,,OUTPCT LIMIT, 279.93,OTHER, 171.54, 479.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33599,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,SELFPAY,SELF PAY, 344.28,,OUTPCT LIMIT, 265.00,OTHER, 171.54, 449.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33600,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,SELFPAY,SELF PAY, 188.69,,OUTPCT LIMIT, 149.90,OTHER, 108.18, 246.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33601,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,SELFPAY,SELF PAY, 239.66,,OUTPCT LIMIT, 167.02,OTHER, 46.09, 313.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33602,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,SELFPAY,SELF PAY, 100.03,,OUTPCT LIMIT, 76.10,OTHER, 46.09, 130.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33603,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,SELFPAY,SELF PAY, 209.45,,OUTPCT LIMIT, 147.35,OTHER, 46.09, 273.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33604,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,SELFPAY,SELF PAY, 303.53,,OUTPCT LIMIT, 227.22,OTHER, 124.32, 396.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33605,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,SELFPAY,SELF PAY, 408.38,,OUTPCT LIMIT, 295.49,OTHER, 124.32, 533.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33606,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,SELFPAY,SELF PAY, 130.24,,OUTPCT LIMIT, 114.40,OTHER, 74.67, 170.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33607,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,SELFPAY,SELF PAY, 193.34,,OUTPCT LIMIT, 155.48,OTHER, 110.85, 252.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33608,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,SELFPAY,SELF PAY, 29.96,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33609,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,SELFPAY,SELF PAY, 29.96,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33610,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,SELFPAY,SELF PAY, 29.96,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33611,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,SELFPAY,SELF PAY, 14.66,,OUTPCT LIMIT, 36.72,OTHER, 8.41, 114.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33612,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,SELFPAY,SELF PAY, 276.26,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33613,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,SELFPAY,SELF PAY, 276.26,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33614,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,SELFPAY,SELF PAY, 682.22,,OUTPCT LIMIT, 526.62,OTHER, 346.21, 891.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33615,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 290.83,OTHER, 143.52, 346.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33616,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,SELFPAY,SELF PAY, 249.95,,OUTPCT LIMIT, 266.67,OTHER, 147.17, 326.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33617,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,SELFPAY,SELF PAY, 231.00,,OUTPCT LIMIT, 162.12,OTHER, 49.24, 301.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33618,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,SELFPAY,SELF PAY, 186.00,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33619,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,SELFPAY,SELF PAY, 186.00,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33620,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,SELFPAY,SELF PAY, 237.75,,OUTPCT LIMIT, 166.97,OTHER, 51.13, 310.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33621,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,SELFPAY,SELF PAY, 65.71,,OUTPCT LIMIT, 54.96,OTHER, 37.67, 85.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33622,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,SELFPAY,SELF PAY, 114.05,,OUTPCT LIMIT, 86.43,OTHER, 51.13, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33623,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,SELFPAY,SELF PAY, 1220.01,,OUTPCT LIMIT, 950.56,OTHER, 656.16, 1594.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33624,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 375.80,OTHER, 121.44, 656.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33625,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,SELFPAY,SELF PAY, 697.50,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33626,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,SELFPAY,SELF PAY, 697.50,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33627,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33628,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33629,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,SELFPAY,SELF PAY, 826.70,,OUTPCT LIMIT, 591.97,OTHER, 225.62, 1080.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33630,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33631,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,SELFPAY,SELF PAY, 349.27,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33632,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,SELFPAY,SELF PAY, 349.27,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33633,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 197.77,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33634,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,SELFPAY,SELF PAY, 783.20,,OUTPCT LIMIT, 563.65,OTHER, 225.62, 1023.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33635,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33636,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,SELFPAY,SELF PAY, 122.25,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33637,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,SELFPAY,SELF PAY, 122.25,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33638,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33639,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33640,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,SELFPAY,SELF PAY, 375.00,,OUTPCT LIMIT, 297.88,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33641,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33642,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,SELFPAY,SELF PAY, 350.81,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33643,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,SELFPAY,SELF PAY, 350.81,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33644,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33645,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33646,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,SELFPAY,SELF PAY, 952.10,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33647,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,SELFPAY,SELF PAY, 952.10,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33648,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,SELFPAY,SELF PAY, 505.86,,OUTPCT LIMIT, 383.08,OTHER, 225.62, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33649,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,SELFPAY,SELF PAY, 952.10,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33650,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33651,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33652,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33653,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33654,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,SELFPAY,SELF PAY, 505.86,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33655,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,SELFPAY,SELF PAY, 505.86,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33656,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,SELFPAY,SELF PAY, 505.86,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33657,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,SELFPAY,SELF PAY, 505.86,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33658,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33659,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33660,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33661,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33662,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,SELFPAY,SELF PAY, 924.10,,OUTPCT LIMIT, 655.39,OTHER, 225.62, 1207.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33663,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33664,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,SELFPAY,SELF PAY, 1943.25,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33665,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,SELFPAY,SELF PAY, 1049.61,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33666,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,SELFPAY,SELF PAY, 327.00,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33667,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,SELFPAY,SELF PAY, 69.00,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33668,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,SELFPAY,SELF PAY, 790.04,,OUTPCT LIMIT, 547.41,OTHER, 138.71, 1032.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33669,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,SELFPAY,SELF PAY, 181.19,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33670,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,SELFPAY,SELF PAY, 181.19,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33671,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,SELFPAY,SELF PAY, 219.40,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33672,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,SELFPAY,SELF PAY, 219.40,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33673,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,SELFPAY,SELF PAY, 459.28,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33674,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,SELFPAY,SELF PAY, 602.25,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33675,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,SELFPAY,SELF PAY, 661.50,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33676,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,SELFPAY,SELF PAY, 459.28,,OUTPCT LIMIT, 332.46,OTHER, 140.42, 600.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33677,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,SELFPAY,SELF PAY, 279.57,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33678,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,SELFPAY,SELF PAY, 279.57,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33679,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,SELFPAY,SELF PAY, 181.19,,OUTPCT LIMIT, 174.98,OTHER, 103.88, 239.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33680,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,SELFPAY,SELF PAY, 181.19,,OUTPCT LIMIT, 136.10,OTHER, 76.16, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33681,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,SELFPAY,SELF PAY, 129.75,,OUTPCT LIMIT, 140.33,OTHER, 74.39, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33682,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,SELFPAY,SELF PAY, 318.75,,OUTPCT LIMIT, 228.33,OTHER, 87.35, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33683,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,SELFPAY,SELF PAY, 40.01,,OUTPCT LIMIT, 34.19,OTHER, 22.94, 52.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33684,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,SELFPAY,SELF PAY, 78.00,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33685,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,SELFPAY,SELF PAY, 245.74,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33686,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,SELFPAY,SELF PAY, 245.74,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33687,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,SELFPAY,SELF PAY, 107.57,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33688,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,SELFPAY,SELF PAY, 107.57,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33689,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,SELFPAY,SELF PAY, 552.14,,OUTPCT LIMIT, 415.63,OTHER, 235.80, 721.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33690,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,SELFPAY,SELF PAY, 2437.50,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33691,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,SELFPAY,SELF PAY, 2437.50,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33692,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,SELFPAY,SELF PAY, 2925.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33693,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,SELFPAY,SELF PAY, 2925.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33694,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,SELFPAY,SELF PAY, 2925.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33695,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,SELFPAY,SELF PAY, 203.42,,OUTPCT LIMIT, 152.82,OTHER, 85.61, 265.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33696,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,SELFPAY,SELF PAY, 222.21,,OUTPCT LIMIT, 165.98,OTHER, 89.47, 290.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33697,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,SELFPAY,SELF PAY, 360.20,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33698,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,SELFPAY,SELF PAY, 360.20,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33699,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,SELFPAY,SELF PAY, 135.15,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33700,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,SELFPAY,SELF PAY, 135.15,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33701,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,SELFPAY,SELF PAY, 428.75,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33702,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,SELFPAY,SELF PAY, 428.75,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33703,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,SELFPAY,SELF PAY, 428.75,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33704,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,SELFPAY,SELF PAY, 123.53,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33705,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,SELFPAY,SELF PAY, 123.58,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33706,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,SELFPAY,SELF PAY, 147.32,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33707,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,SELFPAY,SELF PAY, 147.32,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33708,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,SELFPAY,SELF PAY, 107.96,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33709,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,SELFPAY,SELF PAY, 107.96,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33710,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,SELFPAY,SELF PAY, 115.42,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33711,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,SELFPAY,SELF PAY, 115.42,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33712,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,SELFPAY,SELF PAY, 44.63,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33713,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,SELFPAY,SELF PAY, 44.63,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33714,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,SELFPAY,SELF PAY, 225.63,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33715,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,SELFPAY,SELF PAY, 225.63,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33716,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,SELFPAY,SELF PAY, 128.20,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33717,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,SELFPAY,SELF PAY, 128.20,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33718,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,SELFPAY,SELF PAY, 129.38,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33719,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,SELFPAY,SELF PAY, 129.38,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33720,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,SELFPAY,SELF PAY, 65.97,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33721,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,SELFPAY,SELF PAY, 65.97,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33722,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,SELFPAY,SELF PAY, 72.41,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33723,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,SELFPAY,SELF PAY, 72.41,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33724,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,SELFPAY,SELF PAY, 79.34,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33725,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,SELFPAY,SELF PAY, 79.34,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33726,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,SELFPAY,SELF PAY, 79.34,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33727,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,SELFPAY,SELF PAY, 315.00,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33728,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,SELFPAY,SELF PAY, 101.14,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33729,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,SELFPAY,SELF PAY, 101.14,,OUTPCT LIMIT, 72.71,OTHER, 28.82, 132.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33730,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,SELFPAY,SELF PAY, 92.16,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33731,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,SELFPAY,SELF PAY, 92.10,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33732,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,SELFPAY,SELF PAY, 92.16,,OUTPCT LIMIT, 74.35,OTHER, 52.84, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33733,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,SELFPAY,SELF PAY, 98.30,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33734,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,SELFPAY,SELF PAY, 98.30,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33735,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,SELFPAY,SELF PAY, 98.30,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33736,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,SELFPAY,SELF PAY, 71.35,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33737,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,SELFPAY,SELF PAY, 71.35,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33738,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,SELFPAY,SELF PAY, 50.72,,OUTPCT LIMIT, 47.68,OTHER, 29.08, 66.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33739,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,SELFPAY,SELF PAY, 134.25,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33740,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,SELFPAY,SELF PAY, 134.25,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33741,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,SELFPAY,SELF PAY, 134.25,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33742,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,SELFPAY,SELF PAY, 161.25,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33743,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,SELFPAY,SELF PAY, 161.25,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33744,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,SELFPAY,SELF PAY, 161.25,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33745,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,SELFPAY,SELF PAY, 92.00,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33746,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,SELFPAY,SELF PAY, 92.00,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33747,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,SELFPAY,SELF PAY, 92.00,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33748,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,SELFPAY,SELF PAY, 33.00,,OUTPCT LIMIT, 30.33,OTHER, 18.92, 43.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33749,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,SELFPAY,SELF PAY, 198.78,,OUTPCT LIMIT, 178.52,OTHER, 113.97, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33750,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,SELFPAY,SELF PAY, 235.88,,OUTPCT LIMIT, 202.67,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33751,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,SELFPAY,SELF PAY, 223.33,,OUTPCT LIMIT, 194.50,OTHER, 128.04, 291.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33752,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,SELFPAY,SELF PAY, 111.27,,OUTPCT LIMIT, 106.37,OTHER, 63.79, 145.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33753,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,SELFPAY,SELF PAY, 190.75,,OUTPCT LIMIT, 173.75,OTHER, 109.36, 249.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33754,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,SELFPAY,SELF PAY, 201.63,,OUTPCT LIMIT, 180.83,OTHER, 115.60, 263.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33755,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,SELFPAY,SELF PAY, 237.97,,OUTPCT LIMIT, 204.49,OTHER, 136.43, 310.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33756,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,SELFPAY,SELF PAY, 114.93,,OUTPCT LIMIT, 108.91,OTHER, 65.89, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33757,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,SELFPAY,SELF PAY, 90.53,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33758,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,SELFPAY,SELF PAY, 90.53,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33759,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,SELFPAY,SELF PAY, 90.53,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33760,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,SELFPAY,SELF PAY, 55.05,,OUTPCT LIMIT, 44.69,OTHER, 31.56, 71.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33761,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,SELFPAY,SELF PAY, 95.74,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33762,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,SELFPAY,SELF PAY, 95.74,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33763,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,SELFPAY,SELF PAY, 66.47,,OUTPCT LIMIT, 59.17,OTHER, 38.11, 86.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33764,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,SELFPAY,SELF PAY, 87.00,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33765,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,SELFPAY,SELF PAY, 87.00,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33766,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,SELFPAY,SELF PAY, 87.00,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33767,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,SELFPAY,SELF PAY, 21.75,,OUTPCT LIMIT, 68.90,OTHER, 12.81, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33768,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,SELFPAY,SELF PAY, 107.82,,OUTPCT LIMIT, 93.12,OTHER, 61.82, 140.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33769,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,SELFPAY,SELF PAY, 90.75,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33770,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,SELFPAY,SELF PAY, 198.78,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33771,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,SELFPAY,SELF PAY, 93.00,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33772,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,SELFPAY,SELF PAY, 93.00,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33773,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,SELFPAY,SELF PAY, 93.00,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33774,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,SELFPAY,SELF PAY, 56.25,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33775,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,SELFPAY,SELF PAY, 78.00,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33776,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,SELFPAY,SELF PAY, 105.75,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33777,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,SELFPAY,SELF PAY, 78.00,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33778,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,SELFPAY,SELF PAY, 105.75,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33779,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,SELFPAY,SELF PAY, 56.25,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33780,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,SELFPAY,SELF PAY, 56.25,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33781,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,SELFPAY,SELF PAY, 225.00,,OUTPCT LIMIT, 192.27,OTHER, 129.00, 294.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33782,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33783,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33784,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,SELFPAY,SELF PAY, 181.19,,OUTPCT LIMIT, 145.27,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33785,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,SELFPAY,SELF PAY, 111.56,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33786,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,SELFPAY,SELF PAY, 111.56,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33787,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,SELFPAY,SELF PAY, 189.05,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33788,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,SELFPAY,SELF PAY, 189.05,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33789,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,SELFPAY,SELF PAY, 295.80,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33790,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,SELFPAY,SELF PAY, 295.80,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33791,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,SELFPAY,SELF PAY, 368.48,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33792,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,SELFPAY,SELF PAY, 368.48,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33793,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,SELFPAY,SELF PAY, 35.70,,OUTPCT LIMIT, 30.51,OTHER, 20.47, 46.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33794,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,SELFPAY,SELF PAY, 77.78,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33795,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,SELFPAY,SELF PAY, 77.78,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33796,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,SELFPAY,SELF PAY, 130.05,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33797,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,SELFPAY,SELF PAY, 130.05,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33798,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,SELFPAY,SELF PAY, 191.89,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33799,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,SELFPAY,SELF PAY, 191.89,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33800,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,SELFPAY,SELF PAY, 256.91,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33801,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,SELFPAY,SELF PAY, 256.91,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33802,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,SELFPAY,SELF PAY, 255.00,,OUTPCT LIMIT, 272.06,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33803,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,SELFPAY,SELF PAY, 315.75,,OUTPCT LIMIT, 336.87,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33804,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,SELFPAY,SELF PAY, 108.75,,OUTPCT LIMIT, 111.61,OTHER, 64.03, 142.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33805,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,SELFPAY,SELF PAY, 132.75,,OUTPCT LIMIT, 149.82,OTHER, 78.16, 173.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33806,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,SELFPAY,SELF PAY, 192.00,,OUTPCT LIMIT, 220.11,OTHER, 113.05, 250.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33807,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,SELFPAY,SELF PAY, 201.69,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33808,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,SELFPAY,SELF PAY, 201.69,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33809,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,SELFPAY,SELF PAY, 188.25,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33810,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,SELFPAY,SELF PAY, 188.25,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33811,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,SELFPAY,SELF PAY, 312.00,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33812,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,SELFPAY,SELF PAY, 312.00,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33813,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,SELFPAY,SELF PAY, 222.00,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33814,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,SELFPAY,SELF PAY, 222.00,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33815,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,SELFPAY,SELF PAY, 493.01,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33816,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,SELFPAY,SELF PAY, 493.01,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33817,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,SELFPAY,SELF PAY, 255.00,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33818,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,SELFPAY,SELF PAY, 255.00,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33819,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,SELFPAY,SELF PAY, 773.30,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33820,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,SELFPAY,SELF PAY, 773.30,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33821,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,SELFPAY,SELF PAY, 315.75,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33822,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,SELFPAY,SELF PAY, 315.75,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33823,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,SELFPAY,SELF PAY, 1289.84,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33824,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,SELFPAY,SELF PAY, 1289.84,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33825,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,SELFPAY,SELF PAY, 375.75,,OUTPCT LIMIT, 429.06,OTHER, 221.24, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33826,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,SELFPAY,SELF PAY, 2063.09,,OUTPCT LIMIT, 1514.86,OTHER, 720.78, 2695.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33827,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,SELFPAY,SELF PAY, 756.31,,OUTPCT LIMIT, 646.30,OTHER, 433.62, 988.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33828,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,SELFPAY,SELF PAY, 22.50,,OUTPCT LIMIT, 19.23,OTHER, 12.90, 29.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33829,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,SELFPAY,SELF PAY, 125.59,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33830,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,SELFPAY,SELF PAY, 125.59,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33831,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,SELFPAY,SELF PAY, 197.63,,OUTPCT LIMIT, 167.97,OTHER, 113.31, 258.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33832,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,SELFPAY,SELF PAY, 205.91,,OUTPCT LIMIT, 173.37,OTHER, 118.06, 269.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33833,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,SELFPAY,SELF PAY, 214.84,,OUTPCT LIMIT, 179.18,OTHER, 123.17, 280.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33834,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,SELFPAY,SELF PAY, 242.89,,OUTPCT LIMIT, 197.44,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33835,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,SELFPAY,SELF PAY, 235.88,,OUTPCT LIMIT, 192.88,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33836,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,SELFPAY,SELF PAY, 272.21,,OUTPCT LIMIT, 232.62,OTHER, 156.07, 355.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33837,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,SELFPAY,SELF PAY, 295.80,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33838,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,SELFPAY,SELF PAY, 177.86,,OUTPCT LIMIT, 155.10,OTHER, 101.97, 232.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33839,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,SELFPAY,SELF PAY, 189.98,,OUTPCT LIMIT, 162.99,OTHER, 108.92, 248.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33840,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,SELFPAY,SELF PAY, 207.19,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33841,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,SELFPAY,SELF PAY, 207.19,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33842,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,SELFPAY,SELF PAY, 207.19,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33843,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,SELFPAY,SELF PAY, 211.65,,OUTPCT LIMIT, 177.10,OTHER, 121.35, 276.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33844,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,SELFPAY,SELF PAY, 225.68,,OUTPCT LIMIT, 192.85,OTHER, 129.39, 294.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33845,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,SELFPAY,SELF PAY, 242.89,,OUTPCT LIMIT, 207.56,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33846,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,SELFPAY,SELF PAY, 65.03,,OUTPCT LIMIT, 55.57,OTHER, 37.28, 84.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33847,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,SELFPAY,SELF PAY, 111.56,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33848,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,SELFPAY,SELF PAY, 52.50,,OUTPCT LIMIT, 44.86,OTHER, 30.10, 68.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33849,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,SELFPAY,SELF PAY, 199.54,,OUTPCT LIMIT, 170.52,OTHER, 114.40, 260.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33850,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,SELFPAY,SELF PAY, 39.66,,OUTPCT LIMIT, 33.14,OTHER, 22.74, 51.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33851,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,SELFPAY,SELF PAY, 49.09,,OUTPCT LIMIT, 39.28,OTHER, 28.14, 64.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33852,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,SELFPAY,SELF PAY, 70.79,,OUTPCT LIMIT, 60.49,OTHER, 40.58, 92.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33853,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,SELFPAY,SELF PAY, 16.50,,OUTPCT LIMIT, 14.10,OTHER, 9.46, 21.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33854,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,SELFPAY,SELF PAY, 16.50,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33855,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,SELFPAY,SELF PAY, 111.56,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33856,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,SELFPAY,SELF PAY, 191.25,,OUTPCT LIMIT, 148.65,OTHER, 101.33, 249.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33857,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,SELFPAY,SELF PAY, 206.25,,OUTPCT LIMIT, 166.04,OTHER, 118.25, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33858,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,SELFPAY,SELF PAY, 9.56,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33859,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,SELFPAY,SELF PAY, 9.56,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33860,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,SELFPAY,SELF PAY, 288.75,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33861,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,SELFPAY,SELF PAY, 288.75,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33862,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,SELFPAY,SELF PAY, 455.25,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33863,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,SELFPAY,SELF PAY, 455.25,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33864,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,SELFPAY,SELF PAY, 266.25,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33865,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,SELFPAY,SELF PAY, 266.25,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33866,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,SELFPAY,SELF PAY, 384.00,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33867,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,SELFPAY,SELF PAY, 384.00,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33868,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,SELFPAY,SELF PAY, 658.50,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33869,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,SELFPAY,SELF PAY, 658.50,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33870,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,SELFPAY,SELF PAY, 731.25,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33871,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,SELFPAY,SELF PAY, 731.25,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33872,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,SELFPAY,SELF PAY, 102.00,,OUTPCT LIMIT, 87.16,OTHER, 58.48, 133.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33873,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,SELFPAY,SELF PAY, 48.00,,OUTPCT LIMIT, 41.02,OTHER, 27.52, 62.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33874,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,SELFPAY,SELF PAY, 56.25,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33875,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,SELFPAY,SELF PAY, 2247.00,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33876,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,SELFPAY,SELF PAY, 2247.00,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33877,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,SELFPAY,SELF PAY, 2445.75,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33878,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,SELFPAY,SELF PAY, 2445.75,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33879,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,SELFPAY,SELF PAY, 1725.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33880,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,SELFPAY,SELF PAY, 1725.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33881,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,SELFPAY,SELF PAY, 1725.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33882,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,SELFPAY,SELF PAY, 1500.00,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33883,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,SELFPAY,SELF PAY, 1500.00,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33884,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,SELFPAY,SELF PAY, 1500.00,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33885,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,SELFPAY,SELF PAY, 1500.00,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33886,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,SELFPAY,SELF PAY, 14.36,,OUTPCT LIMIT, 9.74,OTHER, 1.66, 18.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33887,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,SELFPAY,SELF PAY, 84.50,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33888,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,SELFPAY,SELF PAY, 4.50,,OUTPCT LIMIT, 11.82,OTHER, 2.58, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33889,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,SELFPAY,SELF PAY, 67.58,,OUTPCT LIMIT, 57.75,OTHER, 38.74, 88.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33890,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,SELFPAY,SELF PAY, 35.06,,OUTPCT LIMIT, 29.96,OTHER, 20.10, 45.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33891,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,SELFPAY,SELF PAY, 123.98,,OUTPCT LIMIT, 88.75,OTHER, 33.71, 162.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33892,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,SELFPAY,SELF PAY, 78.00,,OUTPCT LIMIT, 58.81,OTHER, 33.71, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33893,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,SELFPAY,SELF PAY, 293.25,,OUTPCT LIMIT, 250.60,OTHER, 168.13, 383.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33894,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,SELFPAY,SELF PAY, 295.80,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33895,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,SELFPAY,SELF PAY, 295.80,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33896,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,SELFPAY,SELF PAY, 31.88,,OUTPCT LIMIT, 35.44,OTHER, 18.28, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33897,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,SELFPAY,SELF PAY, 45.90,,OUTPCT LIMIT, 44.57,OTHER, 26.32, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33898,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,SELFPAY,SELF PAY, 51.00,,OUTPCT LIMIT, 43.58,OTHER, 29.24, 66.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33899,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33900,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,SELFPAY,SELF PAY, 194.85,,OUTPCT LIMIT, 166.51,OTHER, 111.71, 254.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33901,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,SELFPAY,SELF PAY, 70.33,,OUTPCT LIMIT, 60.10,OTHER, 40.32, 91.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33902,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,SELFPAY,SELF PAY, 5.76,,OUTPCT LIMIT, 4.92,OTHER, 3.30, 7.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33903,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,SELFPAY,SELF PAY, 5.58,,OUTPCT LIMIT, 4.77,OTHER, 3.20, 7.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33904,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,SELFPAY,SELF PAY, 15.24,,OUTPCT LIMIT, 13.02,OTHER, 8.74, 19.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33905,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,SELFPAY,SELF PAY, 157.50,,OUTPCT LIMIT, 134.59,OTHER, 90.30, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33906,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,SELFPAY,SELF PAY, 1.59,,OUTPCT LIMIT, 1.36,OTHER, .91, 2.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33907,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,SELFPAY,SELF PAY, 2.46,,OUTPCT LIMIT, 2.10,OTHER, 1.41, 3.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33908,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,SELFPAY,SELF PAY, 30.32,,OUTPCT LIMIT, 25.91,OTHER, 17.38, 39.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33909,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,SELFPAY,SELF PAY, 108.83,,OUTPCT LIMIT, 93.00,OTHER, 62.40, 142.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33910,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,SELFPAY,SELF PAY, 1.71,,OUTPCT LIMIT, 1.46,OTHER, .98, 2.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33911,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,SELFPAY,SELF PAY, 1.20,,OUTPCT LIMIT, 1.03,OTHER, .69, 1.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33912,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,SELFPAY,SELF PAY, 6.03,,OUTPCT LIMIT, 5.15,OTHER, 3.46, 7.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33913,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,SELFPAY,SELF PAY, 13.41,,OUTPCT LIMIT, 11.46,OTHER, 7.69, 17.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33914,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,SELFPAY,SELF PAY, 5.13,,OUTPCT LIMIT, 4.38,OTHER, 2.94, 6.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33915,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,SELFPAY,SELF PAY, 3.00,,OUTPCT LIMIT, 2.56,OTHER, 1.72, 3.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33916,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,SELFPAY,SELF PAY, 8.76,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33917,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,SELFPAY,SELF PAY, 9.75,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33918,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,SELFPAY,SELF PAY, 51.24,,OUTPCT LIMIT, 43.79,OTHER, 29.38, 66.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33919,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,SELFPAY,SELF PAY, 26.94,,OUTPCT LIMIT, 23.02,OTHER, 15.45, 35.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33920,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,SELFPAY,SELF PAY, 7.89,,OUTPCT LIMIT, 6.74,OTHER, 4.52, 10.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33921,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,SELFPAY,SELF PAY, 6.09,,OUTPCT LIMIT, 5.20,OTHER, 3.49, 7.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33922,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,SELFPAY,SELF PAY, 299.25,,OUTPCT LIMIT, 575.18,OTHER, 171.57, 1597.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33923,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,SELFPAY,SELF PAY, 299.25,,OUTPCT LIMIT, 690.66,OTHER, 171.57, 2082.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33924,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,SELFPAY,SELF PAY, 299.25,,OUTPCT LIMIT, 656.15,OTHER, 171.57, 1937.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33925,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,SELFPAY,SELF PAY, 299.25,,OUTPCT LIMIT, 607.70,OTHER, 171.57, 1734.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33926,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,SELFPAY,SELF PAY, 374.25,,OUTPCT LIMIT, 735.35,OTHER, 214.57, 2065.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33927,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,SELFPAY,SELF PAY, 641.25,,OUTPCT LIMIT, 421.89,OTHER, 18.42, 837.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33928,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,SELFPAY,SELF PAY, 3.60,,OUTPCT LIMIT, 3.08,OTHER, 2.06, 4.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33929,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,SELFPAY,SELF PAY, 261.00,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33930,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,SELFPAY,SELF PAY, 261.00,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33931,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,SELFPAY,SELF PAY, 261.00,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33932,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,SELFPAY,SELF PAY, 261.00,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33933,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,SELFPAY,SELF PAY, 261.00,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33934,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,SELFPAY,SELF PAY, 261.00,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33935,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,SELFPAY,SELF PAY, 261.00,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33936,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,SELFPAY,SELF PAY, 261.00,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33937,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,SELFPAY,SELF PAY, 261.00,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33938,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,SELFPAY,SELF PAY, 261.00,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33939,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,SELFPAY,SELF PAY, 261.00,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33940,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,SELFPAY,SELF PAY, 261.00,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33941,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,SELFPAY,SELF PAY, 311.25,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33942,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,SELFPAY,SELF PAY, 311.25,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33943,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,SELFPAY,SELF PAY, 311.25,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33944,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,SELFPAY,SELF PAY, 311.25,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33945,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33946,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33947,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33948,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33949,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33950,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33951,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33952,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33953,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33954,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33955,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33956,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33957,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33958,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33959,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33960,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33961,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33962,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33963,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33964,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,SELFPAY,SELF PAY, 994.50,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33965,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,SELFPAY,SELF PAY, 79.69,,OUTPCT LIMIT, 62.01,OTHER, 42.53, 104.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33966,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,SELFPAY,SELF PAY, 85.50,,OUTPCT LIMIT, 73.06,OTHER, 49.02, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33967,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,SELFPAY,SELF PAY, 75.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33968,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,SELFPAY,SELF PAY, 375.00,,OUTPCT LIMIT, 320.46,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33969,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,SELFPAY,SELF PAY, 31.50,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33970,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,SELFPAY,SELF PAY, 2.25,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33971,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,SELFPAY,SELF PAY, 26.25,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33972,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,SELFPAY,SELF PAY, 2.25,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33973,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,SELFPAY,SELF PAY, 20.25,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33974,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,SELFPAY,SELF PAY, 2.25,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33975,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,SELFPAY,SELF PAY, 11.25,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33976,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,SELFPAY,SELF PAY, 2.36,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33977,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,SELFPAY,SELF PAY, 56.25,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33978,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,SELFPAY,SELF PAY, 2.36,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33979,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,SELFPAY,SELF PAY, 3.39,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33980,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,SELFPAY,SELF PAY, 75.75,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33981,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,SELFPAY,SELF PAY, 4.50,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33982,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,SELFPAY,SELF PAY, 4.50,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33983,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,SELFPAY,SELF PAY, 137.94,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33984,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,SELFPAY,SELF PAY, 4.50,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33985,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,SELFPAY,SELF PAY, 135.00,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33986,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,SELFPAY,SELF PAY, 43.50,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33987,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,SELFPAY,SELF PAY, 43.50,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33988,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,SELFPAY,SELF PAY, 249.12,,OUTPCT LIMIT, 212.89,OTHER, 142.83, 325.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33989,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,SELFPAY,SELF PAY, 91.34,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33990,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,SELFPAY,SELF PAY, 56.25,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33991,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,SELFPAY,SELF PAY, 738.47,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33992,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,SELFPAY,SELF PAY, 537.78,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33993,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,SELFPAY,SELF PAY, 6.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33994,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,SELFPAY,SELF PAY, 4.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33995,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,SELFPAY,SELF PAY, 75.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33996,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,SELFPAY,SELF PAY, 75.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33997,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,SELFPAY,SELF PAY, 75.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33998,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,SELFPAY,SELF PAY, 75.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 33999,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,SELFPAY,SELF PAY, 75.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34000,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,SELFPAY,SELF PAY, 75.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34001,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,SELFPAY,SELF PAY, 75.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34002,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,SELFPAY,SELF PAY, 4.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34003,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,SELFPAY,SELF PAY, 75.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34004,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,SELFPAY,SELF PAY, 76.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34005,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,SELFPAY,SELF PAY, 53.88,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34006,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,SELFPAY,SELF PAY, 53.88,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34007,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,SELFPAY,SELF PAY, 56.25,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34008,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,SELFPAY,SELF PAY, 103.19,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34009,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,SELFPAY,SELF PAY, 2.25,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34010,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,SELFPAY,SELF PAY, 11.25,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34011,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,SELFPAY,SELF PAY, 11.25,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34012,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,SELFPAY,SELF PAY, 11.25,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34013,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,SELFPAY,SELF PAY, 13.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34014,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,SELFPAY,SELF PAY, 18.00,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34015,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,SELFPAY,SELF PAY, 2.25,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34016,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,SELFPAY,SELF PAY, 21.39,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34017,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,SELFPAY,SELF PAY, 21.39,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34018,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,SELFPAY,SELF PAY, 22.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34019,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,SELFPAY,SELF PAY, 22.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34020,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,SELFPAY,SELF PAY, 22.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34021,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,SELFPAY,SELF PAY, 22.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34022,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,SELFPAY,SELF PAY, 2.25,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34023,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,SELFPAY,SELF PAY, 2.24,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34024,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,SELFPAY,SELF PAY, 34.87,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34025,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,SELFPAY,SELF PAY, 7.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34026,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,SELFPAY,SELF PAY, 2.36,,OUTPCT LIMIT, 2.02,OTHER, 1.35, 3.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34027,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,SELFPAY,SELF PAY, 375.75,,OUTPCT LIMIT, 321.10,OTHER, 215.43, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34028,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,SELFPAY,SELF PAY, 429.00,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34029,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34030,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34031,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34032,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34033,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34034,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34035,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34036,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,SELFPAY,SELF PAY, 25.52,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34037,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,SELFPAY,SELF PAY, 114.14,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34038,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,SELFPAY,SELF PAY, 106.98,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34039,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,SELFPAY,SELF PAY, 69.89,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34040,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,SELFPAY,SELF PAY, 64.16,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34041,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,SELFPAY,SELF PAY, 195.22,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34042,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,SELFPAY,SELF PAY, 5704.28,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34043,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,SELFPAY,SELF PAY, 33.92,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34044,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,SELFPAY,SELF PAY, 1335.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34045,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,SELFPAY,SELF PAY, 1335.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34046,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,SELFPAY,SELF PAY, 1335.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34047,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,SELFPAY,SELF PAY, 1335.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34048,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,SELFPAY,SELF PAY, 1335.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34049,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,SELFPAY,SELF PAY, 1335.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34050,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,SELFPAY,SELF PAY, 1800.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34051,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,SELFPAY,SELF PAY, 1335.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34052,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,SELFPAY,SELF PAY, 1335.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34053,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,SELFPAY,SELF PAY, 1335.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34054,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,SELFPAY,SELF PAY, 1335.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34055,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,SELFPAY,SELF PAY, 1335.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34056,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,SELFPAY,SELF PAY, 1335.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34057,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,SELFPAY,SELF PAY, 1050.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34058,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,SELFPAY,SELF PAY, 1050.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34059,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,SELFPAY,SELF PAY, 1050.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34060,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34061,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34062,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34063,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,SELFPAY,SELF PAY, 78.75,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34064,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34065,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,SELFPAY,SELF PAY, 50.35,,OUTPCT LIMIT, 43.03,OTHER, 28.87, 65.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34066,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,SELFPAY,SELF PAY, 7.50,,OUTPCT LIMIT, 6.41,OTHER, 4.30, 9.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34067,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,SELFPAY,SELF PAY, 4350.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34068,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,SELFPAY,SELF PAY, 3600.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34069,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,SELFPAY,SELF PAY, 3600.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34070,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,SELFPAY,SELF PAY, 3600.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34071,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34072,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34073,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,SELFPAY,SELF PAY, 327.00,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34074,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,SELFPAY,SELF PAY, 220.67,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34075,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,SELFPAY,SELF PAY, 227.48,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34076,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,SELFPAY,SELF PAY, 185.33,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34077,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,SELFPAY,SELF PAY, 205.91,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34078,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,SELFPAY,SELF PAY, 425.25,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34079,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,SELFPAY,SELF PAY, 130.05,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34080,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,SELFPAY,SELF PAY, 75.75,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34081,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,SELFPAY,SELF PAY, 76.25,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34082,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,SELFPAY,SELF PAY, 111.56,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34083,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,SELFPAY,SELF PAY, 12.75,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34084,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,SELFPAY,SELF PAY, 21.00,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34085,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34086,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34087,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34088,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34089,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34090,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34091,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34092,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34093,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34094,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34095,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34096,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34097,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,SELFPAY,SELF PAY, 243.75,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34098,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,SELFPAY,SELF PAY, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34099,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,TRICARE,TRICARE, 507.84,,OUTPCT LIMIT, 920.20,OTHER, 507.84, 1127.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34100,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,TRICARE,TRICARE, 375.36,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34101,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,TRICARE,TRICARE, 607.20,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34102,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34103,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34104,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34105,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34106,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34107,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34108,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34109,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34110,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34111,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34112,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34113,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34114,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34115,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34116,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34117,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,TRICARE,TRICARE, 214.97,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34118,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,TRICARE,TRICARE, 214.97,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34119,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,TRICARE,TRICARE, 121.99,,OUTPCT LIMIT, 168.89,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34120,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,TRICARE,TRICARE, 103.33,,OUTPCT LIMIT, 171.36,OTHER, 103.33, 229.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34121,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,TRICARE,TRICARE, 216.93,,OUTPCT LIMIT, 273.87,OTHER, 142.76, 481.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34122,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,TRICARE,TRICARE, 193.86,,OUTPCT LIMIT, 276.81,OTHER, 142.76, 430.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34123,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,TRICARE,TRICARE, 159.90,,OUTPCT LIMIT, 242.16,OTHER, 155.70, 354.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34124,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,TRICARE,TRICARE, 203.58,,OUTPCT LIMIT, 850.02,OTHER, 203.58, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34125,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,TRICARE,TRICARE, 193.86,,OUTPCT LIMIT, 667.92,OTHER, 193.86, 1237.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34126,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,TRICARE,TRICARE, 68.01,,OUTPCT LIMIT, 177.23,OTHER, 68.01, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34127,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,TRICARE,TRICARE, 30.91,,OUTPCT LIMIT, 131.69,OTHER, 30.91, 267.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34128,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,TRICARE,TRICARE, 56.08,,OUTPCT LIMIT, 116.49,OTHER, 56.08, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34129,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,TRICARE,TRICARE, 269.38,,OUTPCT LIMIT, 405.48,OTHER, 256.74, 597.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34130,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,TRICARE,TRICARE, 162.07,,OUTPCT LIMIT, 293.67,OTHER, 162.07, 359.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34131,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,TRICARE,TRICARE, 107.31,,OUTPCT LIMIT, 216.69,OTHER, 107.31, 256.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34132,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,TRICARE,TRICARE, 34.00,,OUTPCT LIMIT, 61.61,OTHER, 34.00, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34133,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,TRICARE,TRICARE, 60.50,,OUTPCT LIMIT, 233.68,OTHER, 60.50, 456.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34134,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,TRICARE,TRICARE, 92.29,,OUTPCT LIMIT, 158.67,OTHER, 92.29, 204.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34135,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,TRICARE,TRICARE, 70.21,,OUTPCT LIMIT, 112.58,OTHER, 70.21, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34136,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,TRICARE,TRICARE, 81.25,,OUTPCT LIMIT, 125.44,OTHER, 81.25, 180.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34137,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,TRICARE,TRICARE, 51.67,,OUTPCT LIMIT, 114.17,OTHER, 51.67, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34138,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,TRICARE,TRICARE, 60.94,,OUTPCT LIMIT, 122.15,OTHER, 60.94, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34139,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,TRICARE,TRICARE, 92.74,,OUTPCT LIMIT, 138.81,OTHER, 86.20, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34140,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,TRICARE,TRICARE, 74.19,,OUTPCT LIMIT, 117.21,OTHER, 74.19, 164.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34141,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,TRICARE,TRICARE, 90.53,,OUTPCT LIMIT, 258.26,OTHER, 90.53, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34142,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,TRICARE,TRICARE, 115.70,,OUTPCT LIMIT, 287.58,OTHER, 115.70, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34143,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,TRICARE,TRICARE, 155.88,,OUTPCT LIMIT, 334.39,OTHER, 155.88, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34144,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,TRICARE,TRICARE, 1053.66,,OUTPCT LIMIT, 1514.68,OTHER, 804.50, 2338.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34145,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,TRICARE,TRICARE, 595.28,,OUTPCT LIMIT, 1306.30,OTHER, 595.28, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34146,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,TRICARE,TRICARE, 268.49,,OUTPCT LIMIT, 925.64,OTHER, 268.49, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34147,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,TRICARE,TRICARE, 87.88,,OUTPCT LIMIT, 389.69,OTHER, 87.88, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34148,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,TRICARE,TRICARE, 120.12,,OUTPCT LIMIT, 427.24,OTHER, 120.12, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34149,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,TRICARE,TRICARE, 146.17,,OUTPCT LIMIT, 457.59,OTHER, 146.17, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34150,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,TRICARE,TRICARE, 102.89,,OUTPCT LIMIT, 732.74,OTHER, 102.89, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34151,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,TRICARE,TRICARE, 299.85,,OUTPCT LIMIT, 1168.49,OTHER, 299.85, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34152,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,TRICARE,TRICARE, 126.74,,OUTPCT LIMIT, 300.44,OTHER, 126.74, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34153,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,TRICARE,TRICARE, 178.41,,OUTPCT LIMIT, 495.14,OTHER, 178.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34154,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,TRICARE,TRICARE, 212.41,,OUTPCT LIMIT, 534.75,OTHER, 212.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34155,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,TRICARE,TRICARE, 245.09,,OUTPCT LIMIT, 572.81,OTHER, 245.09, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34156,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,TRICARE,TRICARE, 218.59,,OUTPCT LIMIT, 541.95,OTHER, 218.59, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34157,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,TRICARE,TRICARE, 250.39,,OUTPCT LIMIT, 578.99,OTHER, 250.39, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34158,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,TRICARE,TRICARE, 766.62,,OUTPCT LIMIT, 1505.88,OTHER, 766.62, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34159,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,TRICARE,TRICARE, 308.68,,OUTPCT LIMIT, 646.89,OTHER, 308.68, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34160,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,TRICARE,TRICARE, 363.44,,OUTPCT LIMIT, 1242.56,OTHER, 363.44, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34161,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,TRICARE,TRICARE, 193.86,,OUTPCT LIMIT, 513.14,OTHER, 193.86, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34162,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,TRICARE,TRICARE, 200.49,,OUTPCT LIMIT, 520.86,OTHER, 200.49, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34163,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,TRICARE,TRICARE, 349.75,,OUTPCT LIMIT, 694.73,OTHER, 349.75, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34164,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,TRICARE,TRICARE, 287.48,,OUTPCT LIMIT, 947.76,OTHER, 287.48, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34165,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,TRICARE,TRICARE, 492.83,,OUTPCT LIMIT, 1393.28,OTHER, 492.83, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34166,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,TRICARE,TRICARE, 24.73,,OUTPCT LIMIT, 56.01,OTHER, 24.73, 76.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34167,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,TRICARE,TRICARE, 149.22,,OUTPCT LIMIT, 185.53,OTHER, 86.20, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34168,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,TRICARE,TRICARE, 57.09,,OUTPCT LIMIT, 97.29,OTHER, 57.09, 126.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34169,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,TRICARE,TRICARE, 56.97,,OUTPCT LIMIT, 97.14,OTHER, 56.97, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34170,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,TRICARE,TRICARE, 22.52,,OUTPCT LIMIT, 57.02,OTHER, 22.52, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34171,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,TRICARE,TRICARE, 189.00,,OUTPCT LIMIT, 372.97,OTHER, 189.00, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34172,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,TRICARE,TRICARE, 538.75,,OUTPCT LIMIT, 1446.78,OTHER, 538.75, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34173,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,TRICARE,TRICARE, 259.66,,OUTPCT LIMIT, 1121.68,OTHER, 259.66, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34174,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,TRICARE,TRICARE, 169.46,,OUTPCT LIMIT, 278.63,OTHER, 165.01, 383.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34175,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,TRICARE,TRICARE, 304.19,,OUTPCT LIMIT, 427.61,OTHER, 296.20, 675.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34176,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,TRICARE,TRICARE, 184.08,,OUTPCT LIMIT, 237.66,OTHER, 143.26, 408.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34177,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,TRICARE,TRICARE, 198.54,,OUTPCT LIMIT, 253.66,OTHER, 143.26, 440.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34178,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,TRICARE,TRICARE, 215.28,,OUTPCT LIMIT, 272.17,OTHER, 143.26, 477.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34179,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,TRICARE,TRICARE, 196.50,,OUTPCT LIMIT, 251.39,OTHER, 143.26, 436.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34180,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,TRICARE,TRICARE, 180.61,,OUTPCT LIMIT, 261.55,OTHER, 143.26, 400.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34181,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,TRICARE,TRICARE, 208.40,,OUTPCT LIMIT, 264.56,OTHER, 143.26, 462.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34182,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,TRICARE,TRICARE, 210.51,,OUTPCT LIMIT, 306.35,OTHER, 204.98, 467.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34183,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,TRICARE,TRICARE, 375.80,,OUTPCT LIMIT, 548.12,OTHER, 309.01, 833.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34184,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,TRICARE,TRICARE, 217.27,,OUTPCT LIMIT, 300.52,OTHER, 132.82, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34185,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,TRICARE,TRICARE, 236.45,,OUTPCT LIMIT, 293.08,OTHER, 132.82, 524.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34186,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,TRICARE,TRICARE, 859.29,,OUTPCT LIMIT, 1023.77,OTHER, 309.01, 1906.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34187,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,TRICARE,TRICARE, 332.97,,OUTPCT LIMIT, 498.22,OTHER, 309.01, 738.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34188,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,TRICARE,TRICARE, 1446.80,,OUTPCT LIMIT, 1703.49,OTHER, 435.32, 3210.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34189,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,TRICARE,TRICARE, 382.87,,OUTPCT LIMIT, 601.46,OTHER, 382.87, 849.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34190,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,TRICARE,TRICARE, 1193.64,,OUTPCT LIMIT, 2228.68,OTHER, 1193.64, 2648.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34191,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,TRICARE,TRICARE, 1296.54,,OUTPCT LIMIT, 2329.49,OTHER, 1296.54, 2877.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34192,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,TRICARE,TRICARE, 56.52,,OUTPCT LIMIT, 163.86,OTHER, 56.52, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34193,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,TRICARE,TRICARE, 149.22,,OUTPCT LIMIT, 200.99,OTHER, 145.30, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34194,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,TRICARE,TRICARE, 53.43,,OUTPCT LIMIT, 93.03,OTHER, 53.43, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34195,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,TRICARE,TRICARE, 5.74,,OUTPCT LIMIT, 22.22,OTHER, 5.74, 43.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34196,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,TRICARE,TRICARE, 146.61,,OUTPCT LIMIT, 224.77,OTHER, 146.61, 325.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34197,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,TRICARE,TRICARE, 77.72,,OUTPCT LIMIT, 251.63,OTHER, 77.72, 451.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34198,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,TRICARE,TRICARE, 241.56,,OUTPCT LIMIT, 1148.36,OTHER, 241.56, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34199,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,TRICARE,TRICARE, 572.76,,OUTPCT LIMIT, 1534.16,OTHER, 572.76, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34200,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,TRICARE,TRICARE, 122.32,,OUTPCT LIMIT, 232.01,OTHER, 122.32, 271.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34201,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,TRICARE,TRICARE, 58.56,,OUTPCT LIMIT, 124.43,OTHER, 57.02, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34202,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,TRICARE,TRICARE, 54.76,,OUTPCT LIMIT, 120.23,OTHER, 53.32, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34203,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,TRICARE,TRICARE, 63.81,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34204,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,TRICARE,TRICARE, 63.81,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34205,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,TRICARE,TRICARE, 3765.08,,OUTPCT LIMIT, 5204.99,OTHER, 2293.79, 8355.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34206,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,TRICARE,TRICARE, 274.68,,OUTPCT LIMIT, 932.84,OTHER, 274.68, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34207,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,TRICARE,TRICARE, 348.95,,OUTPCT LIMIT, 424.57,OTHER, 162.56, 774.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34208,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,TRICARE,TRICARE, 267.85,,OUTPCT LIMIT, 334.89,OTHER, 162.56, 594.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34209,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,TRICARE,TRICARE, 509.97,,OUTPCT LIMIT, 675.88,OTHER, 470.23, 1131.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34210,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,TRICARE,TRICARE, 416.96,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34211,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,TRICARE,TRICARE, 416.96,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34212,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,TRICARE,TRICARE, 152.82,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34213,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,TRICARE,TRICARE, 152.82,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34214,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,TRICARE,TRICARE, 137.55,,OUTPCT LIMIT, 176.70,OTHER, 103.34, 305.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34215,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,TRICARE,TRICARE, 498.99,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34216,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,TRICARE,TRICARE, 498.99,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34217,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,TRICARE,TRICARE, 868.16,,OUTPCT LIMIT, 1089.64,OTHER, 544.52, 1926.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34218,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,TRICARE,TRICARE, 15.46,,OUTPCT LIMIT, 22.43,OTHER, 15.05, 34.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34219,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,TRICARE,TRICARE, 13.71,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34220,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,TRICARE,TRICARE, 13.71,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34221,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,TRICARE,TRICARE, 13.71,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34222,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,TRICARE,TRICARE, 13.71,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34223,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,TRICARE,TRICARE, 13.71,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34224,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,TRICARE,TRICARE, 13.71,,OUTPCT LIMIT, 20.38,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34225,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,TRICARE,TRICARE, 11.04,,OUTPCT LIMIT, 16.02,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34226,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,TRICARE,TRICARE, 452.25,,OUTPCT LIMIT, 579.04,OTHER, 331.58, 1003.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34227,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,TRICARE,TRICARE, 974.17,,OUTPCT LIMIT, 1525.88,OTHER, 974.17, 2161.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34228,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,TRICARE,TRICARE, 2755.58,,OUTPCT LIMIT, 4097.24,OTHER, 2484.68, 6115.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34229,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,TRICARE,TRICARE, 2930.90,,OUTPCT LIMIT, 4480.28,OTHER, 2930.90, 6504.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34230,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,TRICARE,TRICARE, 362.55,,OUTPCT LIMIT, 813.44,OTHER, 362.55, 1095.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34231,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,TRICARE,TRICARE, 3175.99,,OUTPCT LIMIT, 4090.68,OTHER, 1095.12, 7048.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34232,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,TRICARE,TRICARE, 106.69,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34233,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,TRICARE,TRICARE, 106.69,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34234,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,TRICARE,TRICARE, 279.09,,OUTPCT LIMIT, 1187.28,OTHER, 279.09, 2414.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34235,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,TRICARE,TRICARE, 172.67,,OUTPCT LIMIT, 803.17,OTHER, 172.67, 1685.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34236,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,TRICARE,TRICARE, 971.08,,OUTPCT LIMIT, 1733.21,OTHER, 971.08, 2155.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34237,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,TRICARE,TRICARE, 1246.20,,OUTPCT LIMIT, 1757.99,OTHER, 857.80, 2765.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34238,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,TRICARE,TRICARE, 147.05,,OUTPCT LIMIT, 477.65,OTHER, 147.05, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34239,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,TRICARE,TRICARE, 164.28,,OUTPCT LIMIT, 497.71,OTHER, 164.28, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34240,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,TRICARE,TRICARE, 1037.32,,OUTPCT LIMIT, 1514.68,OTHER, 857.80, 2302.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34241,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,TRICARE,TRICARE, 1465.67,,OUTPCT LIMIT, 2013.65,OTHER, 857.80, 3252.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34242,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,TRICARE,TRICARE, 208.88,,OUTPCT LIMIT, 549.67,OTHER, 208.88, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34243,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,TRICARE,TRICARE, 233.61,,OUTPCT LIMIT, 578.48,OTHER, 233.61, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34244,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,TRICARE,TRICARE, 1217.05,,OUTPCT LIMIT, 2205.29,OTHER, 1217.05, 2700.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34245,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,TRICARE,TRICARE, 1490.40,,OUTPCT LIMIT, 2700.60,OTHER, 1490.40, 3307.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34246,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,TRICARE,TRICARE, 515.01,,OUTPCT LIMIT, 718.33,OTHER, 501.48, 1142.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34247,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,TRICARE,TRICARE, 1345.11,,OUTPCT LIMIT, 2437.34,OTHER, 1345.11, 2985.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34248,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,TRICARE,TRICARE, 711.42,,OUTPCT LIMIT, 1780.93,OTHER, 711.42, 2666.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34249,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,TRICARE,TRICARE, 661.96,,OUTPCT LIMIT, 2411.76,OTHER, 661.96, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34250,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,TRICARE,TRICARE, 69.77,,OUTPCT LIMIT, 283.55,OTHER, 69.77, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34251,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,TRICARE,TRICARE, 83.02,,OUTPCT LIMIT, 298.98,OTHER, 83.02, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34252,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,TRICARE,TRICARE, 136.45,,OUTPCT LIMIT, 482.77,OTHER, 136.45, 906.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34253,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,TRICARE,TRICARE, 244.65,,OUTPCT LIMIT, 603.90,OTHER, 244.65, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34254,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,TRICARE,TRICARE, 286.60,,OUTPCT LIMIT, 652.77,OTHER, 286.60, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34255,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,TRICARE,TRICARE, 373.59,,OUTPCT LIMIT, 754.11,OTHER, 373.59, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34256,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,TRICARE,TRICARE, 340.92,,OUTPCT LIMIT, 716.04,OTHER, 340.92, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34257,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,TRICARE,TRICARE, 328.55,,OUTPCT LIMIT, 701.64,OTHER, 328.55, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34258,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,TRICARE,TRICARE, 1679.40,,OUTPCT LIMIT, 2366.55,OTHER, 1148.80, 3726.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34259,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,TRICARE,TRICARE, 110.84,,OUTPCT LIMIT, 623.49,OTHER, 110.84, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34260,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,TRICARE,TRICARE, 159.42,,OUTPCT LIMIT, 256.43,OTHER, 159.42, 353.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34261,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,TRICARE,TRICARE, 122.76,,OUTPCT LIMIT, 637.38,OTHER, 122.76, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34262,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,TRICARE,TRICARE, 122.76,,OUTPCT LIMIT, 982.61,OTHER, 122.76, 2350.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34263,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,TRICARE,TRICARE, 654.45,,OUTPCT LIMIT, 1507.20,OTHER, 654.45, 2085.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34264,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,TRICARE,TRICARE, 1652.91,,OUTPCT LIMIT, 3143.54,OTHER, 1652.91, 3668.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34265,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,TRICARE,TRICARE, 725.99,,OUTPCT LIMIT, 2486.35,OTHER, 725.99, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34266,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,TRICARE,TRICARE, 789.14,,OUTPCT LIMIT, 2559.90,OTHER, 789.14, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34267,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,TRICARE,TRICARE, 786.49,,OUTPCT LIMIT, 1425.12,OTHER, 786.49, 1745.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34268,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,TRICARE,TRICARE, 1265.63,,OUTPCT LIMIT, 1667.02,OTHER, 539.71, 2808.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34269,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,TRICARE,TRICARE, 572.31,,OUTPCT LIMIT, 1786.42,OTHER, 572.31, 3135.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34270,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,TRICARE,TRICARE, 1564.15,,OUTPCT LIMIT, 3662.54,OTHER, 1564.15, 5153.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34271,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,TRICARE,TRICARE, 161.63,,OUTPCT LIMIT, 889.66,OTHER, 161.63, 1963.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34272,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,TRICARE,TRICARE, 177.94,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34273,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,TRICARE,TRICARE, 177.94,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34274,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,TRICARE,TRICARE, 1202.92,,OUTPCT LIMIT, 2146.09,OTHER, 1202.92, 2669.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34275,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 199.77,OTHER, 96.75, 377.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34276,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 266.50,OTHER, 96.75, 657.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34277,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,TRICARE,TRICARE, 1518.22,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34278,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,TRICARE,TRICARE, 1518.22,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34279,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,TRICARE,TRICARE, 495.85,,OUTPCT LIMIT, 719.65,OTHER, 482.83, 1100.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34280,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,TRICARE,TRICARE, 886.98,,OUTPCT LIMIT, 1287.31,OTHER, 863.68, 1968.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34281,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,TRICARE,TRICARE, 200.44,,OUTPCT LIMIT, 290.91,OTHER, 195.18, 444.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34282,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,TRICARE,TRICARE, 748.07,,OUTPCT LIMIT, 2579.17,OTHER, 748.07, 4781.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34283,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,TRICARE,TRICARE, 115.31,,OUTPCT LIMIT, 162.43,OTHER, 112.28, 255.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34284,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,TRICARE,TRICARE, 99.84,,OUTPCT LIMIT, 145.32,OTHER, 97.21, 221.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34285,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,TRICARE,TRICARE, 63.77,,OUTPCT LIMIT, 116.13,OTHER, 62.09, 191.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34286,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,TRICARE,TRICARE, 52.55,,OUTPCT LIMIT, 76.24,OTHER, 51.17, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34287,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,TRICARE,TRICARE, 94.09,,OUTPCT LIMIT, 124.60,OTHER, 86.34, 208.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34288,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34289,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,TRICARE,TRICARE, 37.98,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34290,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34291,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,TRICARE,TRICARE, 60.50,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34292,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34293,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,TRICARE,TRICARE, 116.26,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34294,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34295,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,TRICARE,TRICARE, 37.98,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34296,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34297,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,TRICARE,TRICARE, 125.75,,OUTPCT LIMIT, 171.96,OTHER, 122.45, 279.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34298,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34299,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,TRICARE,TRICARE, 96.93,,OUTPCT LIMIT, 127.74,OTHER, 86.34, 215.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34300,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34301,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,TRICARE,TRICARE, 141.69,,OUTPCT LIMIT, 189.58,OTHER, 137.97, 314.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34302,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34303,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,TRICARE,TRICARE, 87.14,,OUTPCT LIMIT, 116.92,OTHER, 84.85, 193.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34304,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34305,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,TRICARE,TRICARE, 241.13,,OUTPCT LIMIT, 299.54,OTHER, 138.19, 535.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34306,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34307,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,TRICARE,TRICARE, 170.14,,OUTPCT LIMIT, 221.04,OTHER, 138.19, 377.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34308,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34309,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,TRICARE,TRICARE, 130.71,,OUTPCT LIMIT, 177.44,OTHER, 127.28, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34310,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34311,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,TRICARE,TRICARE, 45.81,,OUTPCT LIMIT, 71.21,OTHER, 44.60, 101.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34312,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34313,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,TRICARE,TRICARE, 156.45,,OUTPCT LIMIT, 193.56,OTHER, 86.34, 347.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34314,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34315,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,TRICARE,TRICARE, 183.53,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34316,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,TRICARE,TRICARE, 1293.07,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34317,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,TRICARE,TRICARE, 961.13,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34318,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34319,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34320,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,TRICARE,TRICARE, 988.57,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34321,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,TRICARE,TRICARE, 988.57,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34322,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34323,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34324,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,TRICARE,TRICARE, 1293.07,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34325,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,TRICARE,TRICARE, 1293.07,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34326,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34327,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34328,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,TRICARE,TRICARE, 802.71,,OUTPCT LIMIT, 955.20,OTHER, 283.82, 1781.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34329,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34330,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,TRICARE,TRICARE, 532.15,,OUTPCT LIMIT, 691.35,OTHER, 432.18, 1180.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34331,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34332,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,TRICARE,TRICARE, 697.73,,OUTPCT LIMIT, 887.08,OTHER, 485.27, 1548.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34333,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34334,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,TRICARE,TRICARE, 753.81,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34335,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,TRICARE,TRICARE, 753.98,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34336,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34337,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34338,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,TRICARE,TRICARE, 861.86,,OUTPCT LIMIT, 1055.93,OTHER, 432.18, 1912.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34339,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,TRICARE,TRICARE, 1085.01,,OUTPCT LIMIT, 1302.68,OTHER, 432.18, 2407.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34340,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34341,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34342,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,TRICARE,TRICARE, 359.46,,OUTPCT LIMIT, 513.03,OTHER, 350.02, 797.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34343,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34344,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,TRICARE,TRICARE, 1106.01,,OUTPCT LIMIT, 1290.59,OTHER, 283.82, 2454.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34345,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34346,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,TRICARE,TRICARE, 1150.24,,OUTPCT LIMIT, 1374.81,OTHER, 432.18, 2552.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34347,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34348,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,TRICARE,TRICARE, 1040.37,,OUTPCT LIMIT, 1265.96,OTHER, 485.27, 2308.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34349,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34350,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,TRICARE,TRICARE, 866.53,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34351,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,TRICARE,TRICARE, 866.53,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34352,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,TRICARE,TRICARE, 866.53,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34353,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34354,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34355,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34356,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,TRICARE,TRICARE, 1042.57,,OUTPCT LIMIT, 1270.81,OTHER, 495.38, 2313.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34357,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34358,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,TRICARE,TRICARE, 1352.92,,OUTPCT LIMIT, 1681.52,OTHER, 779.04, 3002.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34359,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34360,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,TRICARE,TRICARE, 998.19,,OUTPCT LIMIT, 1224.87,OTHER, 508.57, 2215.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34361,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34362,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,TRICARE,TRICARE, 1064.70,,OUTPCT LIMIT, 1324.21,OTHER, 616.91, 2362.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34363,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34364,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,TRICARE,TRICARE, 1218.60,,OUTPCT LIMIT, 1532.99,OTHER, 779.04, 2704.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34365,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34366,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,TRICARE,TRICARE, 1006.08,,OUTPCT LIMIT, 1233.59,OTHER, 508.57, 2232.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34367,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34368,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,TRICARE,TRICARE, 1003.32,,OUTPCT LIMIT, 1256.33,OTHER, 616.91, 2226.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34369,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34370,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,TRICARE,TRICARE, 1153.57,,OUTPCT LIMIT, 1461.09,OTHER, 779.04, 2560.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34371,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34372,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,TRICARE,TRICARE, 1168.92,,OUTPCT LIMIT, 1413.66,OTHER, 508.57, 2594.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34373,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34374,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,TRICARE,TRICARE, 1804.78,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34375,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,TRICARE,TRICARE, 1804.78,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34376,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34377,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34378,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,TRICARE,TRICARE, 37.98,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34379,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,TRICARE,TRICARE, 37.98,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34380,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,TRICARE,TRICARE, 37.98,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34381,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,TRICARE,TRICARE, 37.98,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34382,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34383,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34384,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34385,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34386,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,TRICARE,TRICARE, 37.98,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34387,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34388,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,TRICARE,TRICARE, 37.98,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34389,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,TRICARE,TRICARE, 37.98,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34390,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34391,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34392,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,TRICARE,TRICARE, 200.31,,OUTPCT LIMIT, 242.05,OTHER, 86.34, 444.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34393,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,TRICARE,TRICARE, 201.63,,OUTPCT LIMIT, 243.52,OTHER, 86.34, 447.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34394,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34395,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34396,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,TRICARE,TRICARE, 163.90,,OUTPCT LIMIT, 214.14,OTHER, 138.19, 363.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34397,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,TRICARE,TRICARE, 187.31,,OUTPCT LIMIT, 240.03,OTHER, 138.19, 415.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34398,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34399,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34400,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,TRICARE,TRICARE, 195.31,,OUTPCT LIMIT, 248.87,OTHER, 138.19, 433.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34401,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34402,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,TRICARE,TRICARE, 130.71,,OUTPCT LIMIT, 165.10,OTHER, 86.34, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34403,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34404,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,TRICARE,TRICARE, 37.98,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34405,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34406,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,TRICARE,TRICARE, 1034.40,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34407,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,TRICARE,TRICARE, 1034.40,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34408,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,TRICARE,TRICARE, 1034.40,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34409,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34410,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34411,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,TRICARE,TRICARE, 1034.40,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34412,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,TRICARE,TRICARE, 1233.62,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34413,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34414,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,TRICARE,TRICARE, 1538.91,,OUTPCT LIMIT, 1817.25,OTHER, 485.27, 3415.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34415,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34416,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,TRICARE,TRICARE, 1034.40,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34417,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,TRICARE,TRICARE, 1034.40,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34418,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,TRICARE,TRICARE, 1034.40,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34419,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34420,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34421,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34422,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,TRICARE,TRICARE, 2199.18,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34423,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,TRICARE,TRICARE, 1481.87,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34424,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,TRICARE,TRICARE, 1481.87,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34425,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,TRICARE,TRICARE, 1481.87,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34426,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,TRICARE,TRICARE, 1481.87,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34427,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34428,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34429,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34430,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34431,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,TRICARE,TRICARE, 559.07,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34432,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,TRICARE,TRICARE, 1247.52,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34433,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34434,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34435,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,TRICARE,TRICARE, 134.25,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34436,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,TRICARE,TRICARE, 134.25,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34437,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34438,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34439,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,TRICARE,TRICARE, 194.21,,OUTPCT LIMIT, 247.65,OTHER, 138.19, 430.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34440,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34441,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,TRICARE,TRICARE, 287.30,,OUTPCT LIMIT, 350.60,OTHER, 138.19, 637.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34442,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34443,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,TRICARE,TRICARE, 316.27,,OUTPCT LIMIT, 382.63,OTHER, 138.19, 701.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34444,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34445,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,TRICARE,TRICARE, 235.66,,OUTPCT LIMIT, 293.50,OTHER, 138.19, 522.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34446,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34447,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,TRICARE,TRICARE, 210.67,,OUTPCT LIMIT, 265.86,OTHER, 138.19, 467.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34448,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34449,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,TRICARE,TRICARE, 116.26,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34450,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34451,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,TRICARE,TRICARE, 110.40,,OUTPCT LIMIT, 142.64,OTHER, 86.34, 245.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34452,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34453,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,TRICARE,TRICARE, 37.98,,OUTPCT LIMIT, 63.06,OTHER, 36.98, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34454,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,TRICARE,TRICARE, 116.26,,OUTPCT LIMIT, 163.44,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34455,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34456,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,TRICARE,TRICARE, 204.68,,OUTPCT LIMIT, 259.24,OTHER, 138.19, 454.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34457,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34458,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,TRICARE,TRICARE, 121.18,,OUTPCT LIMIT, 166.91,OTHER, 118.00, 268.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34459,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34460,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,TRICARE,TRICARE, 338.38,,OUTPCT LIMIT, 407.08,OTHER, 138.19, 750.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34461,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34462,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,TRICARE,TRICARE, 1258.65,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34463,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,TRICARE,TRICARE, 1258.65,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34464,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,TRICARE,TRICARE, 1258.65,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34465,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34466,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34467,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34468,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,TRICARE,TRICARE, 496.80,,OUTPCT LIMIT, 664.89,OTHER, 483.75, 1102.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34469,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34470,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,TRICARE,TRICARE, 1430.24,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34471,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,TRICARE,TRICARE, 1430.24,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34472,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34473,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34474,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,TRICARE,TRICARE, 1413.12,,OUTPCT LIMIT, 1665.51,OTHER, 432.18, 3136.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34475,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34476,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,TRICARE,TRICARE, 1240.39,,OUTPCT LIMIT, 1439.18,OTHER, 283.82, 2752.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34477,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34478,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,TRICARE,TRICARE, 1401.44,,OUTPCT LIMIT, 1652.58,OTHER, 432.18, 3110.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34479,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34480,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,TRICARE,TRICARE, 1324.80,,OUTPCT LIMIT, 1580.48,OTHER, 485.27, 2940.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34481,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34482,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,TRICARE,TRICARE, 1438.98,,OUTPCT LIMIT, 1712.29,OTHER, 508.57, 3193.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34483,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34484,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,TRICARE,TRICARE, 1604.01,,OUTPCT LIMIT, 1894.78,OTHER, 508.57, 3559.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34485,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34486,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,TRICARE,TRICARE, 1407.91,,OUTPCT LIMIT, 1677.93,OTHER, 508.57, 3124.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34487,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34488,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,TRICARE,TRICARE, 1749.27,,OUTPCT LIMIT, 2119.80,OTHER, 779.04, 3881.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34489,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34490,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,TRICARE,TRICARE, 2128.85,,OUTPCT LIMIT, 2539.54,OTHER, 779.04, 4724.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34491,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34492,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,TRICARE,TRICARE, 1993.80,,OUTPCT LIMIT, 2390.20,OTHER, 779.04, 4424.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34493,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34494,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34495,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34496,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34497,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,TRICARE,TRICARE, 184.40,,OUTPCT LIMIT, 236.81,OTHER, 138.19, 409.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34498,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34499,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,TRICARE,TRICARE, 145.56,,OUTPCT LIMIT, 193.87,OTHER, 138.19, 323.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34500,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34501,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,TRICARE,TRICARE, 1079.40,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34502,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,TRICARE,TRICARE, 1079.40,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34503,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34504,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34505,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,TRICARE,TRICARE, 1042.88,,OUTPCT LIMIT, 1256.10,OTHER, 432.18, 2314.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34506,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34507,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,TRICARE,TRICARE, 704.57,,OUTPCT LIMIT, 894.65,OTHER, 485.27, 1563.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34508,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34509,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,TRICARE,TRICARE, 1474.46,,OUTPCT LIMIT, 1751.53,OTHER, 508.57, 3272.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34510,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34511,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,TRICARE,TRICARE, 2210.08,,OUTPCT LIMIT, 2629.35,OTHER, 779.04, 4904.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34512,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34513,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,TRICARE,TRICARE, 883.20,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34514,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,TRICARE,TRICARE, 883.20,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34515,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,TRICARE,TRICARE, 883.20,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34516,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34517,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34518,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34519,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,TRICARE,TRICARE, 129.89,,OUTPCT LIMIT, 164.19,OTHER, 86.34, 288.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34520,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34521,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,TRICARE,TRICARE, 184.30,,OUTPCT LIMIT, 224.35,OTHER, 86.34, 408.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34522,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34523,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,TRICARE,TRICARE, 170.15,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34524,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,TRICARE,TRICARE, 170.15,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34525,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,TRICARE,TRICARE, 176.49,,OUTPCT LIMIT, 215.71,OTHER, 86.34, 391.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34526,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34527,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34528,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34529,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,TRICARE,TRICARE, 116.26,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34530,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,TRICARE,TRICARE, 116.26,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34531,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,TRICARE,TRICARE, 116.26,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34532,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34533,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34534,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34535,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,TRICARE,TRICARE, 140.43,,OUTPCT LIMIT, 175.84,OTHER, 86.34, 311.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34536,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,TRICARE,TRICARE, 134.29,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34537,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,TRICARE,TRICARE, 134.29,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34538,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34539,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34540,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34541,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,TRICARE,TRICARE, 182.82,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34542,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,TRICARE,TRICARE, 182.82,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34543,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,TRICARE,TRICARE, 187.61,,OUTPCT LIMIT, 240.36,OTHER, 138.19, 416.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34544,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34545,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34546,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34547,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,TRICARE,TRICARE, 180.09,,OUTPCT LIMIT, 219.70,OTHER, 86.34, 399.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34548,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,TRICARE,TRICARE, 175.35,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34549,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,TRICARE,TRICARE, 175.35,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34550,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34551,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34552,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34553,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,TRICARE,TRICARE, 168.21,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34554,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,TRICARE,TRICARE, 172.95,,OUTPCT LIMIT, 211.81,OTHER, 86.34, 383.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34555,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,TRICARE,TRICARE, 168.21,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34556,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34557,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34558,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34559,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,TRICARE,TRICARE, 189.45,,OUTPCT LIMIT, 230.04,OTHER, 86.34, 420.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34560,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,TRICARE,TRICARE, 183.53,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34561,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34562,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34563,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34564,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,TRICARE,TRICARE, 190.15,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34565,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,TRICARE,TRICARE, 190.15,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34566,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,TRICARE,TRICARE, 196.07,,OUTPCT LIMIT, 237.37,OTHER, 86.34, 435.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34567,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34568,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34569,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34570,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,TRICARE,TRICARE, 60.50,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34571,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,TRICARE,TRICARE, 83.90,,OUTPCT LIMIT, 125.68,OTHER, 81.70, 186.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34572,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,TRICARE,TRICARE, 60.50,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34573,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34574,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34575,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34576,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,TRICARE,TRICARE, 174.70,,OUTPCT LIMIT, 213.73,OTHER, 86.34, 387.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34577,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,TRICARE,TRICARE, 169.27,,OUTPCT LIMIT, 207.73,OTHER, 86.34, 375.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34578,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,TRICARE,TRICARE, 169.27,,OUTPCT LIMIT, 207.74,OTHER, 86.34, 375.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34579,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34580,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34581,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34582,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,TRICARE,TRICARE, 196.81,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34583,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,TRICARE,TRICARE, 201.56,,OUTPCT LIMIT, 243.44,OTHER, 86.34, 447.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34584,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,TRICARE,TRICARE, 196.81,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34585,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34586,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34587,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34588,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,TRICARE,TRICARE, 185.91,,OUTPCT LIMIT, 238.48,OTHER, 138.19, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34589,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,TRICARE,TRICARE, 180.00,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34590,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,TRICARE,TRICARE, 180.00,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34591,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34592,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34593,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34594,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,TRICARE,TRICARE, 180.69,,OUTPCT LIMIT, 220.36,OTHER, 86.34, 400.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34595,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,TRICARE,TRICARE, 180.74,,OUTPCT LIMIT, 220.42,OTHER, 86.34, 401.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34596,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,TRICARE,TRICARE, 185.49,,OUTPCT LIMIT, 225.67,OTHER, 86.34, 411.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34597,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34598,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34599,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34600,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,TRICARE,TRICARE, 150.54,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34601,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,TRICARE,TRICARE, 139.39,,OUTPCT LIMIT, 174.69,OTHER, 86.34, 309.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34602,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,TRICARE,TRICARE, 134.64,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34603,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,TRICARE,TRICARE, 134.64,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34604,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,TRICARE,TRICARE, 134.64,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34605,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,TRICARE,TRICARE, 134.64,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34606,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,TRICARE,TRICARE, 134.64,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34607,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,TRICARE,TRICARE, 134.64,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34608,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,TRICARE,TRICARE, 134.64,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34609,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,TRICARE,TRICARE, 134.64,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34610,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,TRICARE,TRICARE, 134.64,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34611,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,TRICARE,TRICARE, 134.64,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34612,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,TRICARE,TRICARE, 134.64,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34613,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34614,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34615,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34616,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34617,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34618,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34619,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34620,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34621,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34622,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34623,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34624,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34625,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34626,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,TRICARE,TRICARE, 835.36,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34627,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,TRICARE,TRICARE, 898.44,,OUTPCT LIMIT, 1061.06,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34628,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,TRICARE,TRICARE, 898.44,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34629,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,TRICARE,TRICARE, 898.44,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34630,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,TRICARE,TRICARE, 898.44,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34631,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,TRICARE,TRICARE, 898.44,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34632,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,TRICARE,TRICARE, 898.44,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34633,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,TRICARE,TRICARE, 295.43,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34634,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,TRICARE,TRICARE, 295.43,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34635,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,TRICARE,TRICARE, 898.44,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34636,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,TRICARE,TRICARE, 898.44,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34637,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,TRICARE,TRICARE, 295.43,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34638,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,TRICARE,TRICARE, 898.44,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34639,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,TRICARE,TRICARE, 898.44,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34640,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,TRICARE,TRICARE, 835.36,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34641,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34642,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34643,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34644,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34645,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34646,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34647,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34648,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34649,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34650,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34651,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34652,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34653,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34654,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34655,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,TRICARE,TRICARE, 1249.28,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34656,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,TRICARE,TRICARE, 1249.28,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34657,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34658,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34659,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34660,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,TRICARE,TRICARE, 595.72,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34661,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,TRICARE,TRICARE, 595.72,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34662,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34663,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34664,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,TRICARE,TRICARE, 845.07,,OUTPCT LIMIT, 1055.55,OTHER, 508.57, 1875.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34665,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34666,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,TRICARE,TRICARE, 1457.39,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34667,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,TRICARE,TRICARE, 1457.39,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34668,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,TRICARE,TRICARE, 1457.39,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34669,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34670,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34671,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34672,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,TRICARE,TRICARE, 1485.84,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34673,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,TRICARE,TRICARE, 1485.84,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34674,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,TRICARE,TRICARE, 1485.84,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34675,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,TRICARE,TRICARE, 1485.84,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34676,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,TRICARE,TRICARE, 1485.84,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34677,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,TRICARE,TRICARE, 1485.84,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34678,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,TRICARE,TRICARE, 1485.84,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34679,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,TRICARE,TRICARE, 1485.84,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34680,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,TRICARE,TRICARE, 1485.84,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34681,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,TRICARE,TRICARE, 1485.84,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34682,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,TRICARE,TRICARE, 1485.84,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34683,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,TRICARE,TRICARE, 1485.84,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34684,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,TRICARE,TRICARE, 1485.84,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34685,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,TRICARE,TRICARE, 1485.84,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34686,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,TRICARE,TRICARE, 1485.84,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34687,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,TRICARE,TRICARE, 1485.84,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34688,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34689,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34690,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34691,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34692,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34693,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34694,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34695,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34696,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34697,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34698,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34699,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34700,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34701,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34702,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34703,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34704,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,TRICARE,TRICARE, 1143.85,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34705,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,TRICARE,TRICARE, 1143.85,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34706,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34707,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34708,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34709,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34710,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34711,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34712,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,TRICARE,TRICARE, 159.10,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34713,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,TRICARE,TRICARE, 159.10,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34714,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,TRICARE,TRICARE, 159.10,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34715,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34716,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34717,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34718,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,TRICARE,TRICARE, 153.66,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34719,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,TRICARE,TRICARE, 153.66,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34720,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,TRICARE,TRICARE, 153.66,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34721,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,TRICARE,TRICARE, 153.66,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34722,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,TRICARE,TRICARE, 153.66,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34723,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34724,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34725,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34726,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34727,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,TRICARE,TRICARE, 201.01,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34728,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,TRICARE,TRICARE, 159.85,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34729,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34730,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34731,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,TRICARE,TRICARE, 164.51,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34732,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,TRICARE,TRICARE, 164.51,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34733,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,TRICARE,TRICARE, 169.26,,OUTPCT LIMIT, 208.23,OTHER, 88.46, 375.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34734,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34735,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34736,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34737,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,TRICARE,TRICARE, 171.98,,OUTPCT LIMIT, 210.73,OTHER, 86.34, 381.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34738,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,TRICARE,TRICARE, 166.55,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34739,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,TRICARE,TRICARE, 166.55,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34740,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34741,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34742,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34743,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,TRICARE,TRICARE, 213.66,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34744,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,TRICARE,TRICARE, 218.41,,OUTPCT LIMIT, 274.41,OTHER, 138.19, 484.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34745,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,TRICARE,TRICARE, 213.66,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34746,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34747,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34748,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34749,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,TRICARE,TRICARE, 333.85,,OUTPCT LIMIT, 402.07,OTHER, 138.19, 740.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34750,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,TRICARE,TRICARE, 327.78,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34751,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,TRICARE,TRICARE, 327.78,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34752,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34753,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34754,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34755,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,TRICARE,TRICARE, 120.11,,OUTPCT LIMIT, 153.37,OTHER, 86.34, 266.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34756,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34757,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,TRICARE,TRICARE, 201.23,,OUTPCT LIMIT, 243.07,OTHER, 86.34, 446.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34758,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,TRICARE,TRICARE, 196.48,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34759,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,TRICARE,TRICARE, 196.48,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34760,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34761,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34762,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34763,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,TRICARE,TRICARE, 37.98,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34764,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,TRICARE,TRICARE, 37.98,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34765,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,TRICARE,TRICARE, 75.96,,OUTPCT LIMIT, 116.89,OTHER, 73.96, 168.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34766,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34767,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34768,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34769,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,TRICARE,TRICARE, 168.25,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34770,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,TRICARE,TRICARE, 168.25,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34771,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,TRICARE,TRICARE, 173.99,,OUTPCT LIMIT, 225.30,OTHER, 138.19, 386.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34772,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34773,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34774,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34775,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,TRICARE,TRICARE, 190.33,,OUTPCT LIMIT, 243.37,OTHER, 138.19, 422.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34776,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,TRICARE,TRICARE, 184.36,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34777,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,TRICARE,TRICARE, 184.36,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34778,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34779,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34780,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34781,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,TRICARE,TRICARE, 150.13,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34782,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,TRICARE,TRICARE, 150.13,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34783,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34784,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34785,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,TRICARE,TRICARE, 207.67,,OUTPCT LIMIT, 250.19,OTHER, 86.34, 460.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34786,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,TRICARE,TRICARE, 202.83,,OUTPCT LIMIT, 244.84,OTHER, 86.34, 450.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34787,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,TRICARE,TRICARE, 202.92,,OUTPCT LIMIT, 244.94,OTHER, 86.34, 450.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34788,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34789,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34790,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34791,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,TRICARE,TRICARE, 102.89,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34792,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,TRICARE,TRICARE, 102.89,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34793,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,TRICARE,TRICARE, 102.89,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34794,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34795,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34796,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34797,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,TRICARE,TRICARE, 137.40,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34798,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,TRICARE,TRICARE, 137.40,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34799,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,TRICARE,TRICARE, 137.40,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34800,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,TRICARE,TRICARE, 137.40,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34801,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,TRICARE,TRICARE, 137.40,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34802,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,TRICARE,TRICARE, 137.40,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34803,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,TRICARE,TRICARE, 137.40,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34804,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,TRICARE,TRICARE, 137.40,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34805,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 179.26,OTHER, 86.34, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34806,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,TRICARE,TRICARE, 137.40,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34807,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,TRICARE,TRICARE, 137.40,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34808,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34809,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34810,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34811,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34812,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34813,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34814,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34815,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34816,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34817,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34818,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34819,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,TRICARE,TRICARE, 1012.13,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34820,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,TRICARE,TRICARE, 1012.13,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34821,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,TRICARE,TRICARE, 1012.13,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34822,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,TRICARE,TRICARE, 1017.89,,OUTPCT LIMIT, 1193.14,OTHER, 283.82, 2258.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34823,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,TRICARE,TRICARE, 1012.13,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34824,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,TRICARE,TRICARE, 1012.13,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34825,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,TRICARE,TRICARE, 1012.13,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34826,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,TRICARE,TRICARE, 1012.13,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34827,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,TRICARE,TRICARE, 1012.13,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34828,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,TRICARE,TRICARE, 1012.13,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34829,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,TRICARE,TRICARE, 1012.13,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34830,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,TRICARE,TRICARE, 1012.13,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34831,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,TRICARE,TRICARE, 1012.13,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34832,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,TRICARE,TRICARE, 1012.13,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34833,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34834,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34835,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34836,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34837,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34838,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34839,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34840,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34841,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34842,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34843,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34844,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34845,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34846,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34847,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,TRICARE,TRICARE, 1204.68,,OUTPCT LIMIT, 1435.02,OTHER, 432.18, 2673.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34848,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,TRICARE,TRICARE, 1198.69,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34849,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,TRICARE,TRICARE, 1198.69,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34850,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34851,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34852,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34853,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,TRICARE,TRICARE, 595.72,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34854,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,TRICARE,TRICARE, 595.72,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34855,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,TRICARE,TRICARE, 595.72,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34856,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34857,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34858,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34859,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,TRICARE,TRICARE, 613.38,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34860,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,TRICARE,TRICARE, 613.38,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34861,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34862,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34863,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,TRICARE,TRICARE, 1306.67,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34864,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,TRICARE,TRICARE, 1306.67,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34865,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,TRICARE,TRICARE, 1306.67,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34866,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,TRICARE,TRICARE, 1306.67,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34867,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,TRICARE,TRICARE, 1306.67,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34868,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,TRICARE,TRICARE, 1306.67,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34869,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34870,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34871,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34872,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34873,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34874,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34875,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,TRICARE,TRICARE, 1598.76,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34876,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,TRICARE,TRICARE, 1598.76,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34877,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34878,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34879,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,TRICARE,TRICARE, 1392.69,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34880,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,TRICARE,TRICARE, 1392.69,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34881,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,TRICARE,TRICARE, 1392.69,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34882,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,TRICARE,TRICARE, 1392.69,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34883,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,TRICARE,TRICARE, 1392.69,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34884,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,TRICARE,TRICARE, 1392.69,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34885,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,TRICARE,TRICARE, 1392.69,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34886,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,TRICARE,TRICARE, 1392.69,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34887,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,TRICARE,TRICARE, 1392.69,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34888,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,TRICARE,TRICARE, 1392.69,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34889,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34890,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34891,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34892,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34893,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34894,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34895,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34896,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34897,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34898,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34899,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,TRICARE,TRICARE, 2032.65,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34900,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,TRICARE,TRICARE, 2032.65,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34901,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,TRICARE,TRICARE, 2032.65,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34902,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,TRICARE,TRICARE, 2032.65,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34903,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,TRICARE,TRICARE, 2032.65,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34904,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34905,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34906,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34907,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34908,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34909,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,TRICARE,TRICARE, 883.20,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34910,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,TRICARE,TRICARE, 1015.68,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34911,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,TRICARE,TRICARE, 1015.68,,OUTPCT LIMIT, 1474.10,OTHER, 989.00, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34912,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,TRICARE,TRICARE, 808.13,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34913,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,TRICARE,TRICARE, 808.13,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34914,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34915,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34916,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34917,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34918,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34919,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,TRICARE,TRICARE, 73.31,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34920,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,TRICARE,TRICARE, 73.31,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34921,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34922,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34923,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,TRICARE,TRICARE, 37.98,,OUTPCT LIMIT, 83.13,OTHER, 36.98, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34924,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 105.42,OTHER, 37.54, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34925,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,TRICARE,TRICARE, 261.83,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34926,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,TRICARE,TRICARE, 261.83,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34927,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34928,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34929,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,TRICARE,TRICARE, 1156.15,,OUTPCT LIMIT, 1346.03,OTHER, 283.82, 2565.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34930,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34931,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,TRICARE,TRICARE, 1303.44,,OUTPCT LIMIT, 1544.22,OTHER, 432.18, 2892.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34932,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34933,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,TRICARE,TRICARE, 1471.95,,OUTPCT LIMIT, 1743.20,OTHER, 485.27, 3266.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34934,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34935,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,TRICARE,TRICARE, 2640.78,,OUTPCT LIMIT, 3113.75,OTHER, 813.20, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34936,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,TRICARE,TRICARE, 156.77,,OUTPCT LIMIT, 473.04,OTHER, 156.77, 813.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34937,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,TRICARE,TRICARE, 1470.01,,OUTPCT LIMIT, 1743.46,OTHER, 495.38, 3262.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34938,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34939,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,TRICARE,TRICARE, 2300.39,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34940,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,TRICARE,TRICARE, 2300.39,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34941,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34942,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34943,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,TRICARE,TRICARE, 2640.78,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34944,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,TRICARE,TRICARE, 2640.78,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34945,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34946,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34947,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,TRICARE,TRICARE, 2958.81,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34948,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,TRICARE,TRICARE, 2958.81,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34949,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,TRICARE,TRICARE, 2958.81,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34950,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34951,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34952,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34953,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,TRICARE,TRICARE, 1418.53,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34954,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,TRICARE,TRICARE, 1418.53,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34955,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34956,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34957,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,TRICARE,TRICARE, 1493.58,,OUTPCT LIMIT, 1837.06,OTHER, 779.04, 3314.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34958,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34959,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,TRICARE,TRICARE, 1104.00,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34960,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,TRICARE,TRICARE, 1787.60,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34961,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34962,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34963,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34964,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,TRICARE,TRICARE, 308.24,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34965,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,TRICARE,TRICARE, 308.24,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34966,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,TRICARE,TRICARE, 308.24,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34967,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34968,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34969,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,TRICARE,TRICARE, 485.11,,OUTPCT LIMIT, 704.06,OTHER, 472.37, 1076.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34970,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 68.02,OTHER, 37.54, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34971,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,TRICARE,TRICARE, 170.63,,OUTPCT LIMIT, 248.14,OTHER, 166.15, 378.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34972,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 230.64,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34973,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,TRICARE,TRICARE, 334.99,,OUTPCT LIMIT, 429.88,OTHER, 249.71, 743.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34974,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 132.91,OTHER, 37.54, 249.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34975,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,TRICARE,TRICARE, 1245.83,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34976,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,TRICARE,TRICARE, 1245.83,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34977,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34978,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34979,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,TRICARE,TRICARE, 154.56,,OUTPCT LIMIT, 224.32,OTHER, 150.50, 343.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34980,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34981,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,TRICARE,TRICARE, 318.17,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34982,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,TRICARE,TRICARE, 318.17,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34983,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,TRICARE,TRICARE, 318.17,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34984,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34985,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34986,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34987,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,TRICARE,TRICARE, 239.60,,OUTPCT LIMIT, 286.59,OTHER, 90.89, 531.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34988,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34989,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,TRICARE,TRICARE, 225.80,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34990,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,TRICARE,TRICARE, 225.80,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34991,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,TRICARE,TRICARE, 225.80,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34992,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,TRICARE,TRICARE, 231.84,,OUTPCT LIMIT, 288.12,OTHER, 133.37, 514.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34993,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34994,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34995,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34996,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34997,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,TRICARE,TRICARE, 424.84,,OUTPCT LIMIT, 503.49,OTHER, 141.55, 942.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34998,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 34999,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,TRICARE,TRICARE, 387.99,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35000,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,TRICARE,TRICARE, 387.99,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35001,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,TRICARE,TRICARE, 387.99,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35002,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,TRICARE,TRICARE, 387.99,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35003,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,TRICARE,TRICARE, 387.99,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35004,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35005,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35006,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35007,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35008,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35009,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,TRICARE,TRICARE, 387.99,,OUTPCT LIMIT, 468.07,OTHER, 163.97, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35010,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 200.02,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35011,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,TRICARE,TRICARE, 349.92,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35012,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,TRICARE,TRICARE, 349.92,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35013,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,TRICARE,TRICARE, 349.92,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35014,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,TRICARE,TRICARE, 349.92,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35015,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,TRICARE,TRICARE, 344.37,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35016,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35017,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35018,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35019,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35020,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35021,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,TRICARE,TRICARE, 344.37,,OUTPCT LIMIT, 414.50,OTHER, 141.55, 764.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35022,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35023,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,TRICARE,TRICARE, 165.60,,OUTPCT LIMIT, 214.87,OTHER, 133.37, 367.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35024,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 163.37,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35025,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,TRICARE,TRICARE, 339.15,,OUTPCT LIMIT, 408.73,OTHER, 141.55, 752.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35026,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35027,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,TRICARE,TRICARE, 428.52,,OUTPCT LIMIT, 507.55,OTHER, 141.55, 950.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35028,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35029,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,TRICARE,TRICARE, 681.83,,OUTPCT LIMIT, 775.60,OTHER, 90.89, 1513.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35030,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35031,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,TRICARE,TRICARE, 234.05,,OUTPCT LIMIT, 290.56,OTHER, 133.37, 519.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35032,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35033,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,TRICARE,TRICARE, 349.14,,OUTPCT LIMIT, 419.77,OTHER, 141.55, 774.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35034,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35035,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,TRICARE,TRICARE, 395.99,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35036,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,TRICARE,TRICARE, 395.99,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35037,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,TRICARE,TRICARE, 395.99,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35038,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35039,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35040,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35041,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,TRICARE,TRICARE, 276.33,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35042,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,TRICARE,TRICARE, 267.13,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35043,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35044,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35045,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,TRICARE,TRICARE, 338.92,,OUTPCT LIMIT, 408.48,OTHER, 141.55, 752.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35046,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35047,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,TRICARE,TRICARE, 706.56,,OUTPCT LIMIT, 813.95,OTHER, 137.10, 1568.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35048,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,TRICARE,TRICARE, 446.74,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35049,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,TRICARE,TRICARE, 446.74,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35050,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35051,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35052,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35053,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,TRICARE,TRICARE, 158.52,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35054,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,TRICARE,TRICARE, 242.88,,OUTPCT LIMIT, 300.33,OTHER, 133.37, 539.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35055,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,TRICARE,TRICARE, 158.52,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35056,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,TRICARE,TRICARE, 158.52,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35057,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,TRICARE,TRICARE, 158.52,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35058,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,TRICARE,TRICARE, 158.52,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35059,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,TRICARE,TRICARE, 158.52,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35060,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,TRICARE,TRICARE, 158.52,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35061,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,TRICARE,TRICARE, 158.52,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35062,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35063,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35064,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35065,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35066,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35067,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35068,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35069,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35070,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35071,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,TRICARE,TRICARE, 293.62,,OUTPCT LIMIT, 426.14,OTHER, 285.90, 651.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35072,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35073,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,TRICARE,TRICARE, 187.50,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35074,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,TRICARE,TRICARE, 187.50,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35075,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,TRICARE,TRICARE, 187.50,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35076,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,TRICARE,TRICARE, 157.65,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35077,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35078,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,TRICARE,TRICARE, 157.65,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35079,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,TRICARE,TRICARE, 157.65,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35080,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,TRICARE,TRICARE, 128.51,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35081,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,TRICARE,TRICARE, 128.51,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35082,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,TRICARE,TRICARE, 62.71,,OUTPCT LIMIT, 91.01,OTHER, 61.06, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35083,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,TRICARE,TRICARE, 81.70,,OUTPCT LIMIT, 78.82,OTHER, 21.15, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35084,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,TRICARE,TRICARE, 128.51,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35085,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,TRICARE,TRICARE, 128.51,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35086,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,TRICARE,TRICARE, 128.51,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35087,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,TRICARE,TRICARE, 128.51,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35088,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35089,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35090,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35091,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35092,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,TRICARE,TRICARE, 216.38,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35093,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,TRICARE,TRICARE, 180.61,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35094,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,TRICARE,TRICARE, 216.38,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35095,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35096,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35097,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,TRICARE,TRICARE, 128.51,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35098,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,TRICARE,TRICARE, 128.51,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35099,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,TRICARE,TRICARE, 128.51,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35100,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,TRICARE,TRICARE, 128.51,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35101,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,TRICARE,TRICARE, 264.96,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35102,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,TRICARE,TRICARE, 183.26,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35103,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,TRICARE,TRICARE, 183.26,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35104,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35105,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35106,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35107,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35108,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35109,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35110,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35111,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,TRICARE,TRICARE, 75.51,,OUTPCT LIMIT, 116.40,OTHER, 73.53, 167.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35112,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,TRICARE,TRICARE, 18.55,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35113,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,TRICARE,TRICARE, 324.50,,OUTPCT LIMIT, 414.07,OTHER, 232.03, 720.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35114,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,TRICARE,TRICARE, 86.55,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35115,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,TRICARE,TRICARE, 155.00,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35116,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,TRICARE,TRICARE, 18.55,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35117,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,TRICARE,TRICARE, 18.55,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35118,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,TRICARE,TRICARE, 130.71,,OUTPCT LIMIT, 154.63,OTHER, 42.36, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35119,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,TRICARE,TRICARE, 155.00,,OUTPCT LIMIT, 204.30,OTHER, 138.19, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35120,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,TRICARE,TRICARE, 18.55,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35121,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,TRICARE,TRICARE, 563.85,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35122,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,TRICARE,TRICARE, 563.85,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35123,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35124,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35125,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,TRICARE,TRICARE, 438.31,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35126,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,TRICARE,TRICARE, 438.31,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35127,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35128,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35129,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,TRICARE,TRICARE, 616.43,,OUTPCT LIMIT, 757.92,OTHER, 320.35, 1367.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35130,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 230.15,OTHER, 99.36, 320.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35131,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,TRICARE,TRICARE, 744.27,,OUTPCT LIMIT, 899.81,OTHER, 322.62, 1651.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35132,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 230.96,OTHER, 99.36, 322.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35133,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,TRICARE,TRICARE, 869.95,,OUTPCT LIMIT, 1092.65,OTHER, 548.80, 1930.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35134,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 311.74,OTHER, 99.36, 548.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35135,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,TRICARE,TRICARE, 690.28,,OUTPCT LIMIT, 864.03,OTHER, 423.08, 1531.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35136,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35137,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,TRICARE,TRICARE, 220.80,,OUTPCT LIMIT, 344.89,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35138,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35139,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,TRICARE,TRICARE, 662.40,,OUTPCT LIMIT, 830.31,OTHER, 410.92, 1470.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35140,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35141,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,TRICARE,TRICARE, 909.70,,OUTPCT LIMIT, 1103.77,OTHER, 410.92, 2018.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35142,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35143,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,TRICARE,TRICARE, 927.36,,OUTPCT LIMIT, 1111.16,OTHER, 359.95, 2058.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35144,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35145,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,TRICARE,TRICARE, 486.86,,OUTPCT LIMIT, 624.07,OTHER, 359.95, 1080.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35146,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35147,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,TRICARE,TRICARE, 530.51,,OUTPCT LIMIT, 672.34,OTHER, 360.01, 1177.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35148,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35149,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,TRICARE,TRICARE, 428.35,,OUTPCT LIMIT, 559.38,OTHER, 360.01, 950.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35150,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35151,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,TRICARE,TRICARE, 1033.06,,OUTPCT LIMIT, 1228.06,OTHER, 360.01, 2292.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35152,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35153,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,TRICARE,TRICARE, 1092.74,,OUTPCT LIMIT, 1294.05,OTHER, 360.01, 2425.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35154,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35155,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,TRICARE,TRICARE, 483.55,,OUTPCT LIMIT, 701.80,OTHER, 470.85, 1073.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35156,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 180.04,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35157,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,TRICARE,TRICARE, 796.43,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35158,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,TRICARE,TRICARE, 796.43,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35159,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35160,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35161,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,TRICARE,TRICARE, 1808.03,,OUTPCT LIMIT, 2267.81,OTHER, 1127.76, 4012.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35162,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35163,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,TRICARE,TRICARE, 641.25,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35164,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,TRICARE,TRICARE, 641.25,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35165,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35166,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35167,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,TRICARE,TRICARE, 513.91,,OUTPCT LIMIT, 635.79,OTHER, 283.54, 1140.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35168,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 217.00,OTHER, 99.36, 283.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35169,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,TRICARE,TRICARE, 825.28,,OUTPCT LIMIT, 984.09,OTHER, 300.36, 1831.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35170,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 223.01,OTHER, 99.36, 300.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35171,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,TRICARE,TRICARE, 854.20,,OUTPCT LIMIT, 1050.06,OTHER, 443.12, 1895.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35172,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 274.00,OTHER, 99.36, 443.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35173,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,TRICARE,TRICARE, 459.26,,OUTPCT LIMIT, 684.67,OTHER, 447.20, 1019.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35174,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,TRICARE,TRICARE, 99.36,,OUTPCT LIMIT, 380.97,OTHER, 99.36, 742.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35175,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,TRICARE,TRICARE, 2103.78,,OUTPCT LIMIT, 2685.69,OTHER, 1509.32, 4668.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35176,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,TRICARE,TRICARE, 176.64,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35177,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,TRICARE,TRICARE, 2178.85,,OUTPCT LIMIT, 2768.70,OTHER, 1509.32, 4835.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35178,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,TRICARE,TRICARE, 176.64,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35179,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,TRICARE,TRICARE, 26.76,,OUTPCT LIMIT, 34.30,OTHER, 19.78, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35180,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,TRICARE,TRICARE, 26.76,,OUTPCT LIMIT, 32.49,OTHER, 12.18, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35181,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,TRICARE,TRICARE, 274.68,,OUTPCT LIMIT, 398.65,OTHER, 267.46, 609.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35182,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,TRICARE,TRICARE, 61.76,,OUTPCT LIMIT, 70.69,OTHER, 10.09, 137.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35183,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,TRICARE,TRICARE, 107.20,,OUTPCT LIMIT, 122.16,OTHER, 15.20, 237.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35184,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,TRICARE,TRICARE, 84.11,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35185,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,TRICARE,TRICARE, 84.11,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35186,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,TRICARE,TRICARE, 72.86,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35187,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,TRICARE,TRICARE, 72.86,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35188,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,TRICARE,TRICARE, 126.17,,OUTPCT LIMIT, 155.85,OTHER, 68.59, 280.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35189,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,TRICARE,TRICARE, 68.89,,OUTPCT LIMIT, 78.98,OTHER, 11.76, 152.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35190,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,TRICARE,TRICARE, 57.85,,OUTPCT LIMIT, 69.30,OTHER, 22.37, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35191,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,TRICARE,TRICARE, 197.40,,OUTPCT LIMIT, 229.30,OTHER, 46.28, 438.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35192,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,TRICARE,TRICARE, 77.84,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35193,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,TRICARE,TRICARE, 74.01,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35194,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,TRICARE,TRICARE, 44.16,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35195,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,TRICARE,TRICARE, 44.16,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35196,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,TRICARE,TRICARE, 68.30,,OUTPCT LIMIT, 80.17,OTHER, 19.50, 151.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35197,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,TRICARE,TRICARE, 42.67,,OUTPCT LIMIT, 54.61,OTHER, 31.20, 94.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35198,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,TRICARE,TRICARE, 68.26,,OUTPCT LIMIT, 80.03,OTHER, 19.08, 151.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35199,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,TRICARE,TRICARE, 67.49,,OUTPCT LIMIT, 79.17,OTHER, 19.08, 149.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35200,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,TRICARE,TRICARE, 55.78,,OUTPCT LIMIT, 63.95,OTHER, 9.52, 123.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35201,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,TRICARE,TRICARE, 20.76,,OUTPCT LIMIT, 28.28,OTHER, 20.21, 46.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35202,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,TRICARE,TRICARE, 71.57,,OUTPCT LIMIT, 83.69,OTHER, 19.08, 158.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35203,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,TRICARE,TRICARE, 43.61,,OUTPCT LIMIT, 53.47,OTHER, 22.03, 96.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35204,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,TRICARE,TRICARE, 68.07,,OUTPCT LIMIT, 79.81,OTHER, 19.08, 151.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35205,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,TRICARE,TRICARE, 36.11,,OUTPCT LIMIT, 44.64,OTHER, 19.78, 80.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35206,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,TRICARE,TRICARE, 127.70,,OUTPCT LIMIT, 145.91,OTHER, 19.78, 283.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35207,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,TRICARE,TRICARE, 54.18,,OUTPCT LIMIT, 64.76,OTHER, 20.36, 120.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35208,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,TRICARE,TRICARE, 106.04,,OUTPCT LIMIT, 121.34,OTHER, 17.16, 235.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35209,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,TRICARE,TRICARE, 72.45,,OUTPCT LIMIT, 84.76,OTHER, 19.50, 160.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35210,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,TRICARE,TRICARE, 114.80,,OUTPCT LIMIT, 134.69,OTHER, 32.53, 254.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35211,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,TRICARE,TRICARE, 76.43,,OUTPCT LIMIT, 90.91,OTHER, 26.84, 169.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35212,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,TRICARE,TRICARE, 84.05,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35213,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,TRICARE,TRICARE, 11.04,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35214,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,TRICARE,TRICARE, 17.66,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35215,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,TRICARE,TRICARE, 17.66,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35216,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,TRICARE,TRICARE, 115.65,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35217,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,TRICARE,TRICARE, 130.27,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35218,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,TRICARE,TRICARE, 74.63,,OUTPCT LIMIT, 108.31,OTHER, 72.67, 165.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35219,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,TRICARE,TRICARE, 66.24,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35220,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,TRICARE,TRICARE, 33.56,,OUTPCT LIMIT, 48.71,OTHER, 32.68, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35221,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,TRICARE,TRICARE, 123.99,,OUTPCT LIMIT, 179.95,OTHER, 120.73, 275.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35222,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,TRICARE,TRICARE, 78.98,,OUTPCT LIMIT, 114.63,OTHER, 76.91, 175.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35223,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,TRICARE,TRICARE, 18.03,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35224,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,TRICARE,TRICARE, 33.12,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35225,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,TRICARE,TRICARE, 18.03,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35226,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,TRICARE,TRICARE, 18.03,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35227,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,TRICARE,TRICARE, 62.27,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35228,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,TRICARE,TRICARE, 46.76,,OUTPCT LIMIT, 67.87,OTHER, 45.53, 103.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35229,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,TRICARE,TRICARE, 70.21,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35230,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,TRICARE,TRICARE, 70.21,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35231,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,TRICARE,TRICARE, 70.21,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35232,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,TRICARE,TRICARE, 59.62,,OUTPCT LIMIT, 86.52,OTHER, 58.05, 132.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35233,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,TRICARE,TRICARE, 37.98,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35234,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,TRICARE,TRICARE, 128.51,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35235,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,TRICARE,TRICARE, 30.56,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35236,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,TRICARE,TRICARE, 30.56,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35237,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,TRICARE,TRICARE, 30.56,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35238,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,TRICARE,TRICARE, 18.23,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35239,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,TRICARE,TRICARE, 18.23,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35240,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,TRICARE,TRICARE, 18.23,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35241,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,TRICARE,TRICARE, 5.74,,OUTPCT LIMIT, 7.12,OTHER, 3.24, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35242,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,TRICARE,TRICARE, 6.62,,OUTPCT LIMIT, 8.07,OTHER, 3.12, 14.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35243,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,TRICARE,TRICARE, 27.95,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35244,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,TRICARE,TRICARE, 27.95,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35245,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,TRICARE,TRICARE, 65.80,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35246,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,TRICARE,TRICARE, 65.80,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35247,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,TRICARE,TRICARE, 108.92,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35248,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,TRICARE,TRICARE, 108.92,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35249,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,TRICARE,TRICARE, 217.27,,OUTPCT LIMIT, 262.66,OTHER, 94.12, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35250,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,TRICARE,TRICARE, 359.52,,OUTPCT LIMIT, 428.98,OTHER, 131.99, 797.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35251,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,TRICARE,TRICARE, 89.35,,OUTPCT LIMIT, 129.68,OTHER, 87.01, 198.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35252,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,TRICARE,TRICARE, 168.69,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35253,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,TRICARE,TRICARE, 168.69,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35254,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,TRICARE,TRICARE, 46.66,,OUTPCT LIMIT, 53.15,OTHER, 6.50, 103.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35255,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,TRICARE,TRICARE, 32.65,,OUTPCT LIMIT, 38.90,OTHER, 11.76, 72.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35256,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,TRICARE,TRICARE, 120.81,,OUTPCT LIMIT, 146.83,OTHER, 55.61, 268.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35257,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,TRICARE,TRICARE, 16.67,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35258,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,TRICARE,TRICARE, 16.67,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35259,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,TRICARE,TRICARE, 23.74,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35260,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,TRICARE,TRICARE, 23.74,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35261,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,TRICARE,TRICARE, 52.99,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35262,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,TRICARE,TRICARE, 52.99,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35263,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,TRICARE,TRICARE, 43.00,,OUTPCT LIMIT, 50.88,OTHER, 13.98, 95.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35264,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,TRICARE,TRICARE, 60.10,,OUTPCT LIMIT, 71.06,OTHER, 19.36, 133.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35265,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,TRICARE,TRICARE, 94.87,,OUTPCT LIMIT, 109.86,OTHER, 20.82, 210.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35266,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,TRICARE,TRICARE, 67.30,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35267,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,TRICARE,TRICARE, 67.30,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35268,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,TRICARE,TRICARE, 52.55,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35269,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,TRICARE,TRICARE, 52.55,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35270,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,TRICARE,TRICARE, 43.92,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35271,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,TRICARE,TRICARE, 43.92,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35272,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,TRICARE,TRICARE, 81.70,,OUTPCT LIMIT, 100.38,OTHER, 42.16, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35273,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,TRICARE,TRICARE, 100.28,,OUTPCT LIMIT, 121.92,OTHER, 46.34, 222.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35274,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,TRICARE,TRICARE, 38.86,,OUTPCT LIMIT, 50.20,OTHER, 30.37, 86.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35275,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,TRICARE,TRICARE, 99.31,,OUTPCT LIMIT, 116.31,OTHER, 27.31, 220.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35276,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,TRICARE,TRICARE, 41.95,,OUTPCT LIMIT, 49.78,OTHER, 14.24, 93.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35277,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,TRICARE,TRICARE, 52.36,,OUTPCT LIMIT, 63.44,OTHER, 23.30, 116.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35278,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,TRICARE,TRICARE, 31.33,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35279,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,TRICARE,TRICARE, 31.33,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35280,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,TRICARE,TRICARE, 28.35,,OUTPCT LIMIT, 33.07,OTHER, 7.22, 62.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35281,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,TRICARE,TRICARE, 16.12,,OUTPCT LIMIT, 19.33,OTHER, 6.31, 35.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35282,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,TRICARE,TRICARE, 28.78,,OUTPCT LIMIT, 33.34,OTHER, 6.38, 63.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35283,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 56.73,OTHER, 22.92, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35284,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,TRICARE,TRICARE, 103.09,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35285,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,TRICARE,TRICARE, 109.96,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35286,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,TRICARE,TRICARE, 103.09,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35287,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,TRICARE,TRICARE, 103.52,,OUTPCT LIMIT, 123.66,OTHER, 38.58, 229.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35288,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,TRICARE,TRICARE, 29.22,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35289,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,TRICARE,TRICARE, 29.22,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35290,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,TRICARE,TRICARE, 29.22,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35291,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,TRICARE,TRICARE, 58.38,,OUTPCT LIMIT, 69.24,OTHER, 19.70, 129.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35292,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,TRICARE,TRICARE, 43.32,,OUTPCT LIMIT, 49.97,OTHER, 8.69, 96.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35293,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,TRICARE,TRICARE, 36.21,,OUTPCT LIMIT, 44.47,OTHER, 18.58, 80.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35294,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,TRICARE,TRICARE, 55.09,,OUTPCT LIMIT, 65.14,OTHER, 17.74, 122.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35295,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,TRICARE,TRICARE, 73.02,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35296,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,TRICARE,TRICARE, 73.02,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35297,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,TRICARE,TRICARE, 48.13,,OUTPCT LIMIT, 59.01,OTHER, 24.29, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35298,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,TRICARE,TRICARE, 107.35,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35299,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,TRICARE,TRICARE, 108.38,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35300,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,TRICARE,TRICARE, 47.72,,OUTPCT LIMIT, 56.46,OTHER, 15.47, 105.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35301,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,TRICARE,TRICARE, 10.60,,OUTPCT LIMIT, 13.69,OTHER, 8.28, 23.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35302,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,TRICARE,TRICARE, 62.81,,OUTPCT LIMIT, 73.71,OTHER, 17.87, 139.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35303,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,TRICARE,TRICARE, 74.16,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35304,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,TRICARE,TRICARE, 74.16,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35305,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,TRICARE,TRICARE, 54.91,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35306,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,TRICARE,TRICARE, 54.91,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35307,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,TRICARE,TRICARE, 164.52,,OUTPCT LIMIT, 190.19,OTHER, 34.69, 365.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35308,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,TRICARE,TRICARE, 186.07,,OUTPCT LIMIT, 214.01,OTHER, 34.69, 412.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35309,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,TRICARE,TRICARE, 40.93,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35310,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,TRICARE,TRICARE, 40.93,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35311,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,TRICARE,TRICARE, 33.56,,OUTPCT LIMIT, 41.70,OTHER, 19.28, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35312,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,TRICARE,TRICARE, 50.43,,OUTPCT LIMIT, 59.73,OTHER, 16.63, 111.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35313,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,TRICARE,TRICARE, 27.01,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35314,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,TRICARE,TRICARE, 27.01,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35315,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,TRICARE,TRICARE, 27.01,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35316,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,TRICARE,TRICARE, 33.76,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35317,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,TRICARE,TRICARE, 33.76,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35318,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,TRICARE,TRICARE, 81.59,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35319,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,TRICARE,TRICARE, 81.59,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35320,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,TRICARE,TRICARE, 37.09,,OUTPCT LIMIT, 45.06,OTHER, 16.97, 82.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35321,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,TRICARE,TRICARE, 66.92,,OUTPCT LIMIT, 76.21,OTHER, 9.31, 148.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35322,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,TRICARE,TRICARE, 60.64,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35323,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,TRICARE,TRICARE, 60.64,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35324,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,TRICARE,TRICARE, 62.41,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35325,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,TRICARE,TRICARE, 62.41,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35326,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,TRICARE,TRICARE, 107.40,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35327,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,TRICARE,TRICARE, 107.40,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35328,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,TRICARE,TRICARE, 79.06,,OUTPCT LIMIT, 93.87,OTHER, 27.06, 175.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35329,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,TRICARE,TRICARE, 113.86,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35330,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,TRICARE,TRICARE, 113.86,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35331,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,TRICARE,TRICARE, 65.80,,OUTPCT LIMIT, 83.83,OTHER, 46.51, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35332,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,TRICARE,TRICARE, 59.17,,OUTPCT LIMIT, 73.72,OTHER, 34.82, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35333,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,TRICARE,TRICARE, 60.50,,OUTPCT LIMIT, 75.45,OTHER, 35.93, 134.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35334,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,TRICARE,TRICARE, 102.78,,OUTPCT LIMIT, 121.64,OTHER, 33.53, 228.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35335,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,TRICARE,TRICARE, 60.97,,OUTPCT LIMIT, 69.17,OTHER, 7.34, 135.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35336,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,TRICARE,TRICARE, 107.53,,OUTPCT LIMIT, 124.67,OTHER, 24.19, 238.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35337,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,TRICARE,TRICARE, 64.92,,OUTPCT LIMIT, 76.46,OTHER, 19.63, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35338,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,TRICARE,TRICARE, 60.08,,OUTPCT LIMIT, 71.48,OTHER, 21.17, 133.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35339,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,TRICARE,TRICARE, 187.13,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35340,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,TRICARE,TRICARE, 68.45,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35341,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,TRICARE,TRICARE, 46.70,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35342,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,TRICARE,TRICARE, 46.70,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35343,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,TRICARE,TRICARE, 46.70,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35344,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,TRICARE,TRICARE, 53.64,,OUTPCT LIMIT, 64.96,OTHER, 23.70, 119.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35345,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,TRICARE,TRICARE, 29.15,,OUTPCT LIMIT, 34.98,OTHER, 11.54, 64.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35346,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,TRICARE,TRICARE, 175.97,,OUTPCT LIMIT, 203.52,OTHER, 37.54, 390.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35347,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,TRICARE,TRICARE, 50.34,,OUTPCT LIMIT, 61.71,OTHER, 25.39, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35348,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,TRICARE,TRICARE, 21.97,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35349,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,TRICARE,TRICARE, 21.97,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35350,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,TRICARE,TRICARE, 21.97,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35351,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,TRICARE,TRICARE, 24.39,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35352,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,TRICARE,TRICARE, 24.39,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35353,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,TRICARE,TRICARE, 24.39,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35354,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,TRICARE,TRICARE, 11.57,,OUTPCT LIMIT, 14.14,OTHER, 5.66, 25.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35355,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,TRICARE,TRICARE, 56.82,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35356,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,TRICARE,TRICARE, 56.82,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35357,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,TRICARE,TRICARE, 49.37,,OUTPCT LIMIT, 57.91,OTHER, 13.97, 109.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35358,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,TRICARE,TRICARE, 31.72,,OUTPCT LIMIT, 37.55,OTHER, 10.37, 70.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35359,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,TRICARE,TRICARE, 79.91,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35360,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,TRICARE,TRICARE, 79.91,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35361,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,TRICARE,TRICARE, 79.74,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35362,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,TRICARE,TRICARE, 79.74,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35363,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,TRICARE,TRICARE, 56.73,,OUTPCT LIMIT, 67.05,OTHER, 18.12, 125.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35364,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,TRICARE,TRICARE, 60.94,,OUTPCT LIMIT, 74.92,OTHER, 31.62, 135.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35365,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,TRICARE,TRICARE, 40.67,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35366,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,TRICARE,TRICARE, 40.67,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35367,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,TRICARE,TRICARE, 40.67,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35368,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,TRICARE,TRICARE, 84.73,,OUTPCT LIMIT, 99.83,OTHER, 25.80, 188.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35369,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,TRICARE,TRICARE, 132.92,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35370,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,TRICARE,TRICARE, 117.19,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35371,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,TRICARE,TRICARE, 117.19,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35372,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,TRICARE,TRICARE, 117.19,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35373,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,TRICARE,TRICARE, 117.19,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35374,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,TRICARE,TRICARE, 117.19,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35375,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,TRICARE,TRICARE, 130.98,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35376,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,TRICARE,TRICARE, 79.07,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35377,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,TRICARE,TRICARE, 121.92,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35378,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,TRICARE,TRICARE, 18.99,,OUTPCT LIMIT, 25.93,OTHER, 18.49, 42.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35379,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,TRICARE,TRICARE, 58.89,,OUTPCT LIMIT, 69.04,OTHER, 16.46, 130.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35380,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,TRICARE,TRICARE, 37.68,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35381,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,TRICARE,TRICARE, 37.68,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35382,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,TRICARE,TRICARE, 37.68,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35383,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,TRICARE,TRICARE, 46.10,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35384,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,TRICARE,TRICARE, 46.10,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35385,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,TRICARE,TRICARE, 46.10,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35386,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,TRICARE,TRICARE, 46.10,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35387,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,TRICARE,TRICARE, 59.75,,OUTPCT LIMIT, 70.04,OTHER, 16.66, 132.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35388,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,TRICARE,TRICARE, 38.18,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35389,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,TRICARE,TRICARE, 50.31,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35390,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,TRICARE,TRICARE, 73.31,,OUTPCT LIMIT, 85.45,OTHER, 18.42, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35391,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,TRICARE,TRICARE, 56.08,,OUTPCT LIMIT, 68.77,OTHER, 28.37, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35392,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,TRICARE,TRICARE, 45.77,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35393,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,TRICARE,TRICARE, 45.77,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35394,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,TRICARE,TRICARE, 52.55,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35395,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,TRICARE,TRICARE, 52.55,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35396,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,TRICARE,TRICARE, 120.43,,OUTPCT LIMIT, 149.05,OTHER, 66.68, 267.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35397,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,TRICARE,TRICARE, 28.70,,OUTPCT LIMIT, 43.46,OTHER, 27.95, 63.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35398,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,TRICARE,TRICARE, 35.64,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35399,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,TRICARE,TRICARE, 35.64,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35400,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,TRICARE,TRICARE, 34.67,,OUTPCT LIMIT, 40.64,OTHER, 9.65, 76.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35401,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,TRICARE,TRICARE, 177.04,,OUTPCT LIMIT, 204.04,OTHER, 34.72, 392.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35402,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,TRICARE,TRICARE, 46.95,,OUTPCT LIMIT, 57.49,OTHER, 23.41, 104.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35403,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,TRICARE,TRICARE, 139.05,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35404,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,TRICARE,TRICARE, 139.05,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35405,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,TRICARE,TRICARE, 73.60,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35406,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,TRICARE,TRICARE, 53.66,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35407,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,TRICARE,TRICARE, 96.71,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35408,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,TRICARE,TRICARE, 96.71,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35409,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,TRICARE,TRICARE, 93.76,,OUTPCT LIMIT, 110.95,OTHER, 30.54, 208.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35410,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,TRICARE,TRICARE, 46.94,,OUTPCT LIMIT, 54.17,OTHER, 9.52, 104.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35411,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,TRICARE,TRICARE, 38.08,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35412,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,TRICARE,TRICARE, 38.08,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35413,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,TRICARE,TRICARE, 73.42,,OUTPCT LIMIT, 86.15,OTHER, 20.81, 162.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35414,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,TRICARE,TRICARE, 120.14,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35415,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,TRICARE,TRICARE, 120.14,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35416,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,TRICARE,TRICARE, 33.56,,OUTPCT LIMIT, 43.75,OTHER, 27.89, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35417,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,TRICARE,TRICARE, 162.67,,OUTPCT LIMIT, 186.61,OTHER, 28.27, 361.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35418,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,TRICARE,TRICARE, 37.98,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35419,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,TRICARE,TRICARE, 41.78,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35420,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,TRICARE,TRICARE, 30.36,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35421,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,TRICARE,TRICARE, 30.36,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35422,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,TRICARE,TRICARE, 24.63,,OUTPCT LIMIT, 28.87,OTHER, 6.85, 54.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35423,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,TRICARE,TRICARE, 11.04,,OUTPCT LIMIT, 13.83,OTHER, 6.82, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35424,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,TRICARE,TRICARE, 36.68,,OUTPCT LIMIT, 45.56,OTHER, 21.01, 81.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35425,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,TRICARE,TRICARE, 77.39,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35426,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,TRICARE,TRICARE, 77.39,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35427,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,TRICARE,TRICARE, 84.52,,OUTPCT LIMIT, 102.79,OTHER, 39.19, 187.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35428,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,TRICARE,TRICARE, 81.86,,OUTPCT LIMIT, 97.17,OTHER, 27.91, 181.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35429,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,TRICARE,TRICARE, 73.00,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35430,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,TRICARE,TRICARE, 78.75,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35431,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,TRICARE,TRICARE, 78.75,,OUTPCT LIMIT, 93.39,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35432,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,TRICARE,TRICARE, 21.16,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35433,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,TRICARE,TRICARE, 21.16,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35434,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,TRICARE,TRICARE, 51.17,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35435,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,TRICARE,TRICARE, 51.17,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35436,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,TRICARE,TRICARE, 51.17,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35437,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,TRICARE,TRICARE, 36.12,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35438,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,TRICARE,TRICARE, 36.12,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35439,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,TRICARE,TRICARE, 37.72,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35440,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,TRICARE,TRICARE, 175.80,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35441,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,TRICARE,TRICARE, 78.10,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35442,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,TRICARE,TRICARE, 67.35,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35443,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,TRICARE,TRICARE, 177.69,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35444,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,TRICARE,TRICARE, 115.03,,OUTPCT LIMIT, 136.35,OTHER, 38.44, 255.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35445,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,TRICARE,TRICARE, 84.68,,OUTPCT LIMIT, 103.27,OTHER, 40.46, 187.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35446,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,TRICARE,TRICARE, 62.71,,OUTPCT LIMIT, 76.88,OTHER, 31.67, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35447,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,TRICARE,TRICARE, 155.44,,OUTPCT LIMIT, 178.83,OTHER, 29.15, 344.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35448,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,TRICARE,TRICARE, 73.23,,OUTPCT LIMIT, 88.43,OTHER, 31.30, 162.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35449,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,TRICARE,TRICARE, 25.66,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35450,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,TRICARE,TRICARE, 25.66,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35451,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,TRICARE,TRICARE, 39.91,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35452,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,TRICARE,TRICARE, 39.91,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35453,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,TRICARE,TRICARE, 8.19,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35454,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,TRICARE,TRICARE, 156.84,,OUTPCT LIMIT, 180.72,OTHER, 30.61, 348.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35455,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,TRICARE,TRICARE, 271.46,,OUTPCT LIMIT, 302.95,OTHER, 11.66, 602.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35456,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,TRICARE,TRICARE, 66.16,,OUTPCT LIMIT, 81.90,OTHER, 36.67, 146.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35457,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,TRICARE,TRICARE, 103.34,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35458,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,TRICARE,TRICARE, 103.34,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35459,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,TRICARE,TRICARE, 103.34,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35460,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,TRICARE,TRICARE, 103.34,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35461,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,TRICARE,TRICARE, 71.91,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35462,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,TRICARE,TRICARE, 71.91,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35463,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,TRICARE,TRICARE, 92.10,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35464,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,TRICARE,TRICARE, 92.10,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35465,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,TRICARE,TRICARE, 46.05,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35466,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,TRICARE,TRICARE, 46.05,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35467,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,TRICARE,TRICARE, 65.89,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35468,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,TRICARE,TRICARE, 65.89,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35469,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,TRICARE,TRICARE, 65.89,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35470,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,TRICARE,TRICARE, 42.39,,OUTPCT LIMIT, 51.95,OTHER, 21.29, 94.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35471,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,TRICARE,TRICARE, 61.29,,OUTPCT LIMIT, 73.53,OTHER, 24.19, 136.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35472,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,TRICARE,TRICARE, 123.65,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35473,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,TRICARE,TRICARE, 123.65,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35474,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,TRICARE,TRICARE, 40.63,,OUTPCT LIMIT, 49.79,OTHER, 20.42, 90.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35475,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,TRICARE,TRICARE, 33.04,,OUTPCT LIMIT, 38.32,OTHER, 7.46, 73.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35476,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,TRICARE,TRICARE, 30.90,,OUTPCT LIMIT, 35.99,OTHER, 7.63, 68.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35477,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,TRICARE,TRICARE, 48.96,,OUTPCT LIMIT, 58.51,OTHER, 18.37, 108.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35478,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,TRICARE,TRICARE, 33.61,,OUTPCT LIMIT, 39.13,OTHER, 8.27, 74.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35479,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,TRICARE,TRICARE, 67.41,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35480,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,TRICARE,TRICARE, 67.41,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35481,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,TRICARE,TRICARE, 66.10,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35482,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,TRICARE,TRICARE, 66.10,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35483,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,TRICARE,TRICARE, 109.86,,OUTPCT LIMIT, 126.89,OTHER, 22.69, 243.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35484,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,TRICARE,TRICARE, 71.19,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35485,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,TRICARE,TRICARE, 71.19,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35486,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,TRICARE,TRICARE, 34.16,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35487,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,TRICARE,TRICARE, 34.16,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35488,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,TRICARE,TRICARE, 34.16,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35489,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,TRICARE,TRICARE, 18.72,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35490,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,TRICARE,TRICARE, 18.72,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35491,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,TRICARE,TRICARE, 27.42,,OUTPCT LIMIT, 31.87,OTHER, 6.50, 60.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35492,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,TRICARE,TRICARE, 33.78,,OUTPCT LIMIT, 39.10,OTHER, 7.32, 74.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35493,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,TRICARE,TRICARE, 65.43,,OUTPCT LIMIT, 76.33,OTHER, 16.72, 145.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35494,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,TRICARE,TRICARE, 89.53,,OUTPCT LIMIT, 103.71,OTHER, 19.75, 198.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35495,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,TRICARE,TRICARE, 47.73,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35496,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,TRICARE,TRICARE, 47.73,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35497,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,TRICARE,TRICARE, 47.73,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35498,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,TRICARE,TRICARE, 70.97,,OUTPCT LIMIT, 85.61,OTHER, 29.96, 157.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35499,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,TRICARE,TRICARE, 83.09,,OUTPCT LIMIT, 97.04,OTHER, 21.67, 184.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35500,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,TRICARE,TRICARE, 37.28,,OUTPCT LIMIT, 42.88,OTHER, 6.94, 82.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35501,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,TRICARE,TRICARE, 38.43,,OUTPCT LIMIT, 43.80,OTHER, 5.47, 85.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35502,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,TRICARE,TRICARE, 15.41,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35503,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,TRICARE,TRICARE, 15.41,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35504,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,TRICARE,TRICARE, 18.67,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35505,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,TRICARE,TRICARE, 18.67,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35506,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35507,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,TRICARE,TRICARE, 37.94,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35508,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,TRICARE,TRICARE, 38.43,,OUTPCT LIMIT, 44.71,OTHER, 9.31, 85.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35509,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,TRICARE,TRICARE, 32.82,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35510,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,TRICARE,TRICARE, 32.82,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35511,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,TRICARE,TRICARE, 17.22,,OUTPCT LIMIT, 19.92,OTHER, 3.66, 38.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35512,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,TRICARE,TRICARE, 28.12,,OUTPCT LIMIT, 32.63,OTHER, 6.46, 62.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35513,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,TRICARE,TRICARE, 81.97,,OUTPCT LIMIT, 96.77,OTHER, 25.78, 181.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35514,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,TRICARE,TRICARE, 109.82,,OUTPCT LIMIT, 129.31,OTHER, 33.04, 243.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35515,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,TRICARE,TRICARE, 114.37,,OUTPCT LIMIT, 130.54,OTHER, 17.06, 253.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35516,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,TRICARE,TRICARE, 84.64,,OUTPCT LIMIT, 98.34,OTHER, 19.93, 187.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35517,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,TRICARE,TRICARE, 75.73,,OUTPCT LIMIT, 89.00,OTHER, 22.06, 168.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35518,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,TRICARE,TRICARE, 85.67,,OUTPCT LIMIT, 98.22,OTHER, 14.66, 190.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35519,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,TRICARE,TRICARE, 46.39,,OUTPCT LIMIT, 54.63,OTHER, 13.99, 102.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35520,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,TRICARE,TRICARE, 57.85,,OUTPCT LIMIT, 70.40,OTHER, 27.00, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35521,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,TRICARE,TRICARE, 25.73,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35522,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,TRICARE,TRICARE, 25.56,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35523,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,TRICARE,TRICARE, 25.73,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35524,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,TRICARE,TRICARE, 11.48,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35525,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,TRICARE,TRICARE, 11.48,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35526,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,TRICARE,TRICARE, 11.48,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35527,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,TRICARE,TRICARE, 11.48,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35528,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,TRICARE,TRICARE, 36.30,,OUTPCT LIMIT, 41.60,OTHER, 6.14, 80.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35529,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,TRICARE,TRICARE, 22.96,,OUTPCT LIMIT, 26.32,OTHER, 3.89, 50.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35530,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,TRICARE,TRICARE, 31.16,,OUTPCT LIMIT, 36.35,OTHER, 7.93, 69.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35531,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,TRICARE,TRICARE, 75.07,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35532,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,TRICARE,TRICARE, 33.07,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35533,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,TRICARE,TRICARE, 66.91,,OUTPCT LIMIT, 76.67,OTHER, 11.26, 148.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35534,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,TRICARE,TRICARE, 524.78,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35535,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,TRICARE,TRICARE, 142.64,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35536,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35537,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35538,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35539,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35540,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35541,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35542,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35543,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35544,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35545,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35546,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35547,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35548,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35549,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35550,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35551,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35552,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35553,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35554,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35555,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35556,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35557,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35558,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35559,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35560,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35561,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35562,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35563,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35564,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35565,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35566,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35567,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35568,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35569,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35570,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35571,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35572,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,TRICARE,TRICARE, 27.22,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35573,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35574,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35575,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35576,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35577,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,TRICARE,TRICARE, 14.18,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35578,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35579,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35580,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35581,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35582,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35583,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35584,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35585,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35586,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35587,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35588,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35589,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35590,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35591,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35592,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35593,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35594,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35595,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,TRICARE,TRICARE, 29.45,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35596,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,TRICARE,TRICARE, 165.49,,OUTPCT LIMIT, 189.29,OTHER, 26.45, 367.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35597,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,TRICARE,TRICARE, 101.04,,OUTPCT LIMIT, 115.17,OTHER, 14.46, 224.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35598,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,TRICARE,TRICARE, 58.87,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35599,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,TRICARE,TRICARE, 99.48,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35600,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,TRICARE,TRICARE, 40.77,,OUTPCT LIMIT, 48.91,OTHER, 16.07, 90.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35601,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,TRICARE,TRICARE, 38.64,,OUTPCT LIMIT, 45.23,OTHER, 10.51, 85.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35602,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,TRICARE,TRICARE, 13.84,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35603,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,TRICARE,TRICARE, 13.84,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35604,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,TRICARE,TRICARE, 49.57,,OUTPCT LIMIT, 59.25,OTHER, 18.65, 110.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35605,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,TRICARE,TRICARE, 77.10,,OUTPCT LIMIT, 93.98,OTHER, 36.65, 171.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35606,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,TRICARE,TRICARE, 116.34,,OUTPCT LIMIT, 137.37,OTHER, 36.65, 258.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35607,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,TRICARE,TRICARE, 65.98,,OUTPCT LIMIT, 78.46,OTHER, 23.14, 146.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35608,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,TRICARE,TRICARE, 57.52,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35609,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,TRICARE,TRICARE, 57.38,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35610,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,TRICARE,TRICARE, 63.96,,OUTPCT LIMIT, 77.69,OTHER, 29.26, 141.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35611,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,TRICARE,TRICARE, 53.12,,OUTPCT LIMIT, 63.19,OTHER, 18.65, 117.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35612,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,TRICARE,TRICARE, 53.05,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35613,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,TRICARE,TRICARE, 57.59,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35614,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,TRICARE,TRICARE, 62.46,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35615,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,TRICARE,TRICARE, 62.46,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35616,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,TRICARE,TRICARE, 62.46,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35617,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,TRICARE,TRICARE, 62.46,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35618,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,TRICARE,TRICARE, 62.54,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35619,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,TRICARE,TRICARE, 62.46,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35620,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,TRICARE,TRICARE, 53.37,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35621,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,TRICARE,TRICARE, 49.75,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35622,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,TRICARE,TRICARE, 70.21,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35623,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,TRICARE,TRICARE, 107.38,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35624,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,TRICARE,TRICARE, 103.67,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35625,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,TRICARE,TRICARE, 11.04,,OUTPCT LIMIT, 15.65,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35626,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,TRICARE,TRICARE, 65.82,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35627,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,TRICARE,TRICARE, 67.67,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35628,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,TRICARE,TRICARE, 70.53,,OUTPCT LIMIT, 85.12,OTHER, 29.96, 156.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35629,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,TRICARE,TRICARE, 87.10,,OUTPCT LIMIT, 103.45,OTHER, 29.96, 193.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35630,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,TRICARE,TRICARE, 59.75,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35631,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,TRICARE,TRICARE, 155.66,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35632,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,TRICARE,TRICARE, 44.10,,OUTPCT LIMIT, 50.54,OTHER, 7.46, 97.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35633,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,TRICARE,TRICARE, 73.44,,OUTPCT LIMIT, 88.87,OTHER, 32.17, 162.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35634,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,TRICARE,TRICARE, 53.43,,OUTPCT LIMIT, 66.43,OTHER, 30.83, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35635,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,TRICARE,TRICARE, 47.26,,OUTPCT LIMIT, 57.43,OTHER, 21.72, 104.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35636,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,TRICARE,TRICARE, 232.39,,OUTPCT LIMIT, 265.06,OTHER, 33.95, 515.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35637,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,TRICARE,TRICARE, 64.92,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35638,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,TRICARE,TRICARE, 64.92,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35639,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,TRICARE,TRICARE, 89.42,,OUTPCT LIMIT, 111.82,OTHER, 54.34, 198.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35640,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,TRICARE,TRICARE, 144.80,,OUTPCT LIMIT, 176.22,OTHER, 67.64, 321.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35641,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,TRICARE,TRICARE, 71.32,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35642,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,TRICARE,TRICARE, 71.32,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35643,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,TRICARE,TRICARE, 59.17,,OUTPCT LIMIT, 68.73,OTHER, 13.84, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35644,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,TRICARE,TRICARE, 72.03,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35645,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,TRICARE,TRICARE, 92.74,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35646,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,TRICARE,TRICARE, 59.17,,OUTPCT LIMIT, 70.10,OTHER, 19.60, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35647,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,TRICARE,TRICARE, 40.62,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35648,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,TRICARE,TRICARE, 40.62,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35649,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,TRICARE,TRICARE, 154.12,,OUTPCT LIMIT, 191.67,OTHER, 89.24, 342.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35650,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,TRICARE,TRICARE, 8.26,,OUTPCT LIMIT, 12.31,OTHER, 8.04, 18.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35651,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,TRICARE,TRICARE, 15.42,,OUTPCT LIMIT, 18.56,OTHER, 6.34, 34.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35652,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,TRICARE,TRICARE, 28.08,,OUTPCT LIMIT, 36.21,OTHER, 21.67, 62.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35653,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,TRICARE,TRICARE, 46.81,,OUTPCT LIMIT, 55.25,OTHER, 14.66, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35654,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,TRICARE,TRICARE, 32.29,,OUTPCT LIMIT, 40.13,OTHER, 18.58, 71.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35655,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,TRICARE,TRICARE, 56.08,,OUTPCT LIMIT, 66.54,OTHER, 19.00, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35656,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,TRICARE,TRICARE, 74.64,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35657,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,TRICARE,TRICARE, 74.64,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35658,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,TRICARE,TRICARE, 74.64,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35659,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,TRICARE,TRICARE, 20.46,,OUTPCT LIMIT, 26.75,OTHER, 17.29, 45.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35660,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,TRICARE,TRICARE, 42.80,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35661,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,TRICARE,TRICARE, 114.82,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35662,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,TRICARE,TRICARE, 41.51,,OUTPCT LIMIT, 50.83,OTHER, 20.72, 92.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35663,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,TRICARE,TRICARE, 48.13,,OUTPCT LIMIT, 59.00,OTHER, 24.26, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35664,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,TRICARE,TRICARE, 53.55,,OUTPCT LIMIT, 64.46,OTHER, 22.02, 118.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35665,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,TRICARE,TRICARE, 48.18,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35666,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,TRICARE,TRICARE, 48.18,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35667,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,TRICARE,TRICARE, 80.80,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35668,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,TRICARE,TRICARE, 48.63,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35669,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,TRICARE,TRICARE, 48.63,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35670,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,TRICARE,TRICARE, 54.32,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35671,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,TRICARE,TRICARE, 54.32,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35672,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,TRICARE,TRICARE, 34.89,,OUTPCT LIMIT, 43.51,OTHER, 20.72, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35673,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,TRICARE,TRICARE, 39.03,,OUTPCT LIMIT, 47.68,OTHER, 19.00, 86.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35674,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,TRICARE,TRICARE, 46.81,,OUTPCT LIMIT, 58.39,OTHER, 27.86, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35675,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,TRICARE,TRICARE, 65.78,,OUTPCT LIMIT, 77.47,OTHER, 19.86, 145.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35676,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,TRICARE,TRICARE, 52.27,,OUTPCT LIMIT, 62.50,OTHER, 19.74, 116.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35677,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,TRICARE,TRICARE, 38.54,,OUTPCT LIMIT, 46.75,OTHER, 17.35, 85.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35678,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,TRICARE,TRICARE, 33.56,,OUTPCT LIMIT, 41.14,OTHER, 16.94, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35679,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,TRICARE,TRICARE, 57.33,,OUTPCT LIMIT, 67.08,OTHER, 15.47, 127.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35680,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,TRICARE,TRICARE, 41.85,,OUTPCT LIMIT, 50.52,OTHER, 17.84, 92.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35681,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,TRICARE,TRICARE, 21.99,,OUTPCT LIMIT, 28.18,OTHER, 16.21, 48.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35682,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,TRICARE,TRICARE, 43.47,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35683,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,TRICARE,TRICARE, 43.47,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35684,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,TRICARE,TRICARE, 33.12,,OUTPCT LIMIT, 41.16,OTHER, 19.07, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35685,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,TRICARE,TRICARE, 37.24,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35686,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,TRICARE,TRICARE, 37.24,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35687,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,TRICARE,TRICARE, 37.24,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35688,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,TRICARE,TRICARE, 38.53,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35689,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,TRICARE,TRICARE, 39.85,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35690,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,TRICARE,TRICARE, 39.85,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35691,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,TRICARE,TRICARE, 40.55,,OUTPCT LIMIT, 49.38,OTHER, 19.07, 89.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35692,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,TRICARE,TRICARE, 68.45,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35693,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,TRICARE,TRICARE, 68.45,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35694,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,TRICARE,TRICARE, 323.16,,OUTPCT LIMIT, 361.76,OTHER, 18.55, 717.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35695,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,TRICARE,TRICARE, 141.75,,OUTPCT LIMIT, 161.64,OTHER, 20.54, 314.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35696,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,TRICARE,TRICARE, 123.55,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35697,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,TRICARE,TRICARE, 123.55,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35698,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,TRICARE,TRICARE, 67.52,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35699,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,TRICARE,TRICARE, 67.52,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35700,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,TRICARE,TRICARE, 67.52,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35701,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,TRICARE,TRICARE, 105.54,,OUTPCT LIMIT, 152.44,OTHER, 102.77, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35702,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,TRICARE,TRICARE, 190.27,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35703,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,TRICARE,TRICARE, 190.27,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35704,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,TRICARE,TRICARE, 190.27,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35705,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,TRICARE,TRICARE, 72.27,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35706,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,TRICARE,TRICARE, 72.27,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35707,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,TRICARE,TRICARE, 72.27,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35708,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,TRICARE,TRICARE, 72.27,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35709,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,TRICARE,TRICARE, 72.27,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35710,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,TRICARE,TRICARE, 131.20,,OUTPCT LIMIT, 146.86,OTHER, 7.46, 291.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35711,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,TRICARE,TRICARE, 48.58,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35712,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,TRICARE,TRICARE, 48.58,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35713,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,TRICARE,TRICARE, 48.58,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35714,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,TRICARE,TRICARE, 40.22,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35715,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,TRICARE,TRICARE, 38.22,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35716,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,TRICARE,TRICARE, 40.22,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35717,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,TRICARE,TRICARE, 190.27,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35718,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,TRICARE,TRICARE, 190.27,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35719,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,TRICARE,TRICARE, 172.89,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35720,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,TRICARE,TRICARE, 61.60,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35721,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,TRICARE,TRICARE, 61.60,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35722,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,TRICARE,TRICARE, 262.41,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35723,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,TRICARE,TRICARE, 262.41,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35724,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,TRICARE,TRICARE, 262.41,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35725,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,TRICARE,TRICARE, 262.41,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35726,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,TRICARE,TRICARE, 262.41,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35727,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,TRICARE,TRICARE, 262.41,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35728,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,TRICARE,TRICARE, 61.60,,OUTPCT LIMIT, 76.50,OTHER, 35.20, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35729,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,TRICARE,TRICARE, 115.26,,OUTPCT LIMIT, 149.18,OTHER, 91.25, 255.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35730,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,TRICARE,TRICARE, 70.42,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35731,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,TRICARE,TRICARE, 70.42,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35732,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,TRICARE,TRICARE, 24.89,,OUTPCT LIMIT, 30.76,OTHER, 13.60, 55.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35733,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,TRICARE,TRICARE, 63.02,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35734,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,TRICARE,TRICARE, 63.02,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35735,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,TRICARE,TRICARE, 67.84,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35736,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,TRICARE,TRICARE, 67.84,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35737,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,TRICARE,TRICARE, 68.93,,OUTPCT LIMIT, 78.99,OTHER, 11.64, 152.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35738,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,TRICARE,TRICARE, 39.79,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35739,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,TRICARE,TRICARE, 39.79,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35740,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,TRICARE,TRICARE, 39.79,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35741,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,TRICARE,TRICARE, 34.99,,OUTPCT LIMIT, 40.96,OTHER, 9.55, 77.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35742,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,TRICARE,TRICARE, 37.90,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35743,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,TRICARE,TRICARE, 37.90,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35744,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,TRICARE,TRICARE, 37.90,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35745,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,TRICARE,TRICARE, 71.88,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35746,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,TRICARE,TRICARE, 71.88,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35747,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,TRICARE,TRICARE, 64.99,,OUTPCT LIMIT, 74.74,OTHER, 12.11, 144.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35748,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,TRICARE,TRICARE, 78.95,,OUTPCT LIMIT, 91.00,OTHER, 15.55, 175.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35749,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,TRICARE,TRICARE, 59.02,,OUTPCT LIMIT, 68.31,OTHER, 12.82, 130.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35750,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,TRICARE,TRICARE, 14.57,,OUTPCT LIMIT, 17.74,OTHER, 6.84, 32.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35751,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,TRICARE,TRICARE, 18.47,,OUTPCT LIMIT, 22.99,OTHER, 10.78, 40.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35752,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,TRICARE,TRICARE, 25.61,,OUTPCT LIMIT, 29.95,OTHER, 6.84, 56.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35753,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,TRICARE,TRICARE, 35.67,,OUTPCT LIMIT, 42.41,OTHER, 12.46, 79.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35754,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,TRICARE,TRICARE, 24.99,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35755,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,TRICARE,TRICARE, 23.27,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35756,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,TRICARE,TRICARE, 23.27,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35757,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,TRICARE,TRICARE, 23.36,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35758,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,TRICARE,TRICARE, 23.36,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35759,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,TRICARE,TRICARE, 32.82,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35760,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,TRICARE,TRICARE, 32.82,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35761,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,TRICARE,TRICARE, 23.78,,OUTPCT LIMIT, 28.29,OTHER, 8.38, 52.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35762,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,TRICARE,TRICARE, 56.08,,OUTPCT LIMIT, 68.72,OTHER, 28.16, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35763,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,TRICARE,TRICARE, 267.04,,OUTPCT LIMIT, 299.39,OTHER, 17.26, 592.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35764,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,TRICARE,TRICARE, 33.57,,OUTPCT LIMIT, 40.67,OTHER, 14.88, 74.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35765,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,TRICARE,TRICARE, 35.38,,OUTPCT LIMIT, 43.08,OTHER, 16.61, 78.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35766,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,TRICARE,TRICARE, 105.54,,OUTPCT LIMIT, 121.25,OTHER, 19.08, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35767,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,TRICARE,TRICARE, 56.08,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35768,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,TRICARE,TRICARE, 85.23,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35769,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,TRICARE,TRICARE, 85.23,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35770,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,TRICARE,TRICARE, 85.23,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35771,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,TRICARE,TRICARE, 85.23,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35772,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,TRICARE,TRICARE, 85.23,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35773,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,TRICARE,TRICARE, 166.55,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35774,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,TRICARE,TRICARE, 166.55,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35775,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,TRICARE,TRICARE, 69.39,,OUTPCT LIMIT, 100.71,OTHER, 67.57, 153.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35776,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,TRICARE,TRICARE, 187.00,,OUTPCT LIMIT, 221.47,OTHER, 61.69, 415.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35777,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,TRICARE,TRICARE, 58.24,,OUTPCT LIMIT, 76.43,OTHER, 50.53, 129.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35778,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,TRICARE,TRICARE, 213.29,,OUTPCT LIMIT, 265.03,OTHER, 122.54, 473.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35779,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,TRICARE,TRICARE, 85.23,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35780,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,TRICARE,TRICARE, 66.24,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35781,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,TRICARE,TRICARE, 66.24,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35782,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,TRICARE,TRICARE, 273.82,,OUTPCT LIMIT, 445.68,OTHER, 266.63, 607.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35783,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,TRICARE,TRICARE, 44.16,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35784,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,TRICARE,TRICARE, 44.16,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35785,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,TRICARE,TRICARE, 44.16,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35786,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,TRICARE,TRICARE, 164.55,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35787,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,TRICARE,TRICARE, 164.55,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35788,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35789,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,TRICARE,TRICARE, 146.17,,OUTPCT LIMIT, 173.66,OTHER, 50.53, 324.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35790,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,TRICARE,TRICARE, 56.08,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35791,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,TRICARE,TRICARE, 77.37,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35792,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,TRICARE,TRICARE, 270.23,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35793,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,TRICARE,TRICARE, 119.22,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35794,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,TRICARE,TRICARE, 119.22,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35795,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,TRICARE,TRICARE, 51.17,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35796,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,TRICARE,TRICARE, 51.17,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35797,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,TRICARE,TRICARE, 34.89,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35798,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,TRICARE,TRICARE, 34.89,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35799,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,TRICARE,TRICARE, 34.89,,OUTPCT LIMIT, 44.25,OTHER, 23.81, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35800,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,TRICARE,TRICARE, 11.04,,OUTPCT LIMIT, 17.88,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35801,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,TRICARE,TRICARE, 85.58,,OUTPCT LIMIT, 100.14,OTHER, 23.14, 189.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35802,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,TRICARE,TRICARE, 644.29,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35803,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,TRICARE,TRICARE, 644.29,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35804,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,TRICARE,TRICARE, 45.93,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35805,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,TRICARE,TRICARE, 45.93,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35806,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,TRICARE,TRICARE, 245.09,,OUTPCT LIMIT, 294.34,OTHER, 97.97, 543.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35807,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35808,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35809,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,TRICARE,TRICARE, 13.69,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35810,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,TRICARE,TRICARE, 13.69,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35811,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,TRICARE,TRICARE, 49.64,,OUTPCT LIMIT, 56.81,OTHER, 8.06, 110.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35812,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,TRICARE,TRICARE, 33.88,,OUTPCT LIMIT, 39.98,OTHER, 10.56, 75.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35813,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,TRICARE,TRICARE, 34.00,,OUTPCT LIMIT, 41.73,OTHER, 17.35, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35814,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,TRICARE,TRICARE, 2619.76,,OUTPCT LIMIT, 3802.17,OTHER, 2550.94, 5813.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35815,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,TRICARE,TRICARE, 49.75,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35816,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,TRICARE,TRICARE, 49.75,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35817,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,TRICARE,TRICARE, 13.03,,OUTPCT LIMIT, 23.30,OTHER, 12.69, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35818,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,TRICARE,TRICARE, 26.28,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35819,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,TRICARE,TRICARE, 13.14,,OUTPCT LIMIT, 23.42,OTHER, 12.79, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35820,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,TRICARE,TRICARE, 56.97,,OUTPCT LIMIT, 82.68,OTHER, 55.47, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35821,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35822,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,TRICARE,TRICARE, 67.56,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35823,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,TRICARE,TRICARE, 67.56,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35824,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,TRICARE,TRICARE, 61.36,,OUTPCT LIMIT, 89.06,OTHER, 59.75, 136.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35825,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,TRICARE,TRICARE, 22.08,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35826,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,TRICARE,TRICARE, 22.08,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35827,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,TRICARE,TRICARE, 262.04,,OUTPCT LIMIT, 356.50,OTHER, 255.16, 581.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35828,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,TRICARE,TRICARE, 547.49,,OUTPCT LIMIT, 687.64,OTHER, 345.38, 1214.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35829,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,TRICARE,TRICARE, 138.88,,OUTPCT LIMIT, 201.57,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35830,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35831,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35832,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,TRICARE,TRICARE, 37.54,,OUTPCT LIMIT, 60.00,OTHER, 36.55, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35833,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,TRICARE,TRICARE, 22.72,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35834,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,TRICARE,TRICARE, 22.72,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35835,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35836,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35837,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35838,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,TRICARE,TRICARE, 4.86,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35839,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,TRICARE,TRICARE, 4.86,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35840,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,TRICARE,TRICARE, 4.86,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35841,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,TRICARE,TRICARE, 4.86,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35842,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,TRICARE,TRICARE, 35.21,,OUTPCT LIMIT, 51.11,OTHER, 34.29, 78.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35843,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,TRICARE,TRICARE, 60.37,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35844,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,TRICARE,TRICARE, 60.37,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35845,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35846,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,TRICARE,TRICARE, 69.68,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35847,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,TRICARE,TRICARE, 69.68,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35848,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35849,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35850,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,TRICARE,TRICARE, 75.47,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35851,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,TRICARE,TRICARE, 75.47,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35852,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,TRICARE,TRICARE, 4.42,,OUTPCT LIMIT, 12.78,OTHER, 4.30, 33.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35853,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,TRICARE,TRICARE, 14.60,,OUTPCT LIMIT, 17.36,OTHER, 5.09, 32.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35854,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,TRICARE,TRICARE, 134.21,,OUTPCT LIMIT, 184.48,OTHER, 130.68, 297.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35855,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,TRICARE,TRICARE, 150.37,,OUTPCT LIMIT, 202.35,OTHER, 146.42, 333.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35856,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,TRICARE,TRICARE, 65.33,,OUTPCT LIMIT, 99.37,OTHER, 63.61, 144.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35857,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,TRICARE,TRICARE, 67.15,,OUTPCT LIMIT, 88.44,OTHER, 59.56, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35858,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,TRICARE,TRICARE, 86.50,,OUTPCT LIMIT, 131.72,OTHER, 84.22, 191.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35859,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,TRICARE,TRICARE, 85.04,,OUTPCT LIMIT, 117.05,OTHER, 82.81, 188.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35860,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,TRICARE,TRICARE, 129.93,,OUTPCT LIMIT, 179.75,OTHER, 126.51, 288.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35861,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,TRICARE,TRICARE, 112.41,,OUTPCT LIMIT, 158.52,OTHER, 109.46, 249.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35862,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,TRICARE,TRICARE, 135.77,,OUTPCT LIMIT, 186.21,OTHER, 132.20, 301.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35863,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,TRICARE,TRICARE, 64.96,,OUTPCT LIMIT, 83.96,OTHER, 50.93, 144.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35864,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,TRICARE,TRICARE, 104.75,,OUTPCT LIMIT, 167.44,OTHER, 102.00, 232.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35865,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,TRICARE,TRICARE, 109.12,,OUTPCT LIMIT, 172.28,OTHER, 106.26, 242.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35866,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,TRICARE,TRICARE, 26.28,,OUTPCT LIMIT, 49.86,OTHER, 25.59, 87.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35867,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,TRICARE,TRICARE, 109.49,,OUTPCT LIMIT, 141.43,OTHER, 85.51, 242.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35868,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,TRICARE,TRICARE, 46.64,,OUTPCT LIMIT, 69.71,OTHER, 45.42, 103.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35869,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,TRICARE,TRICARE, 123.72,,OUTPCT LIMIT, 177.65,OTHER, 120.47, 274.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35870,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,TRICARE,TRICARE, 134.40,,OUTPCT LIMIT, 189.46,OTHER, 130.87, 298.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35871,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,TRICARE,TRICARE, 216.22,,OUTPCT LIMIT, 279.93,OTHER, 171.54, 479.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35872,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,TRICARE,TRICARE, 202.71,,OUTPCT LIMIT, 265.00,OTHER, 171.54, 449.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35873,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,TRICARE,TRICARE, 111.10,,OUTPCT LIMIT, 149.90,OTHER, 108.18, 246.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35874,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,TRICARE,TRICARE, 141.11,,OUTPCT LIMIT, 167.02,OTHER, 46.09, 313.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35875,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,TRICARE,TRICARE, 58.90,,OUTPCT LIMIT, 76.10,OTHER, 46.09, 130.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35876,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,TRICARE,TRICARE, 123.33,,OUTPCT LIMIT, 147.35,OTHER, 46.09, 273.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35877,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,TRICARE,TRICARE, 178.72,,OUTPCT LIMIT, 227.22,OTHER, 124.32, 396.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35878,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,TRICARE,TRICARE, 240.45,,OUTPCT LIMIT, 295.49,OTHER, 124.32, 533.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35879,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,TRICARE,TRICARE, 76.68,,OUTPCT LIMIT, 114.40,OTHER, 74.67, 170.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35880,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,TRICARE,TRICARE, 113.84,,OUTPCT LIMIT, 155.48,OTHER, 110.85, 252.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35881,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,TRICARE,TRICARE, 17.64,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35882,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,TRICARE,TRICARE, 17.64,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35883,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,TRICARE,TRICARE, 17.64,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35884,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,TRICARE,TRICARE, 8.63,,OUTPCT LIMIT, 36.72,OTHER, 8.41, 114.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35885,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,TRICARE,TRICARE, 162.66,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35886,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,TRICARE,TRICARE, 162.66,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35887,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,TRICARE,TRICARE, 401.69,,OUTPCT LIMIT, 526.62,OTHER, 346.21, 891.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35888,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 290.83,OTHER, 143.52, 346.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35889,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,TRICARE,TRICARE, 147.17,,OUTPCT LIMIT, 266.67,OTHER, 147.17, 326.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35890,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,TRICARE,TRICARE, 136.01,,OUTPCT LIMIT, 162.12,OTHER, 49.24, 301.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35891,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,TRICARE,TRICARE, 109.52,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35892,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,TRICARE,TRICARE, 109.52,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35893,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,TRICARE,TRICARE, 139.99,,OUTPCT LIMIT, 166.97,OTHER, 51.13, 310.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35894,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,TRICARE,TRICARE, 38.69,,OUTPCT LIMIT, 54.96,OTHER, 37.67, 85.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35895,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,TRICARE,TRICARE, 67.15,,OUTPCT LIMIT, 86.43,OTHER, 51.13, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35896,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,TRICARE,TRICARE, 718.34,,OUTPCT LIMIT, 950.56,OTHER, 656.16, 1594.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35897,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 375.80,OTHER, 121.44, 656.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35898,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,TRICARE,TRICARE, 410.69,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35899,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,TRICARE,TRICARE, 410.69,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35900,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35901,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35902,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,TRICARE,TRICARE, 486.76,,OUTPCT LIMIT, 591.97,OTHER, 225.62, 1080.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35903,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35904,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,TRICARE,TRICARE, 205.65,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35905,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,TRICARE,TRICARE, 205.65,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35906,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 197.77,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35907,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,TRICARE,TRICARE, 461.15,,OUTPCT LIMIT, 563.65,OTHER, 225.62, 1023.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35908,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35909,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,TRICARE,TRICARE, 71.98,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35910,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,TRICARE,TRICARE, 71.98,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35911,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35912,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35913,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,TRICARE,TRICARE, 220.80,,OUTPCT LIMIT, 297.88,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35914,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35915,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,TRICARE,TRICARE, 206.56,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35916,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,TRICARE,TRICARE, 206.56,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35917,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35918,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35919,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,TRICARE,TRICARE, 560.59,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35920,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,TRICARE,TRICARE, 560.59,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35921,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,TRICARE,TRICARE, 297.85,,OUTPCT LIMIT, 383.08,OTHER, 225.62, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35922,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,TRICARE,TRICARE, 560.59,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35923,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35924,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35925,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35926,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35927,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,TRICARE,TRICARE, 297.85,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35928,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,TRICARE,TRICARE, 297.85,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35929,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,TRICARE,TRICARE, 297.85,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35930,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,TRICARE,TRICARE, 297.85,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35931,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35932,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35933,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35934,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35935,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,TRICARE,TRICARE, 544.11,,OUTPCT LIMIT, 655.39,OTHER, 225.62, 1207.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35936,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35937,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,TRICARE,TRICARE, 1144.19,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35938,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,TRICARE,TRICARE, 618.01,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35939,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,TRICARE,TRICARE, 192.54,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35940,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,TRICARE,TRICARE, 40.63,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35941,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,TRICARE,TRICARE, 465.17,,OUTPCT LIMIT, 547.41,OTHER, 138.71, 1032.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35942,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,TRICARE,TRICARE, 106.69,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35943,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,TRICARE,TRICARE, 106.69,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35944,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,TRICARE,TRICARE, 129.18,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35945,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,TRICARE,TRICARE, 129.18,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35946,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,TRICARE,TRICARE, 270.42,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35947,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,TRICARE,TRICARE, 354.60,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35948,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,TRICARE,TRICARE, 389.49,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35949,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,TRICARE,TRICARE, 270.42,,OUTPCT LIMIT, 332.46,OTHER, 140.42, 600.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35950,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,TRICARE,TRICARE, 164.61,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35951,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,TRICARE,TRICARE, 164.61,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35952,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,TRICARE,TRICARE, 106.69,,OUTPCT LIMIT, 174.98,OTHER, 103.88, 239.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35953,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,TRICARE,TRICARE, 106.69,,OUTPCT LIMIT, 136.10,OTHER, 76.16, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35954,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,TRICARE,TRICARE, 76.40,,OUTPCT LIMIT, 140.33,OTHER, 74.39, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35955,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,TRICARE,TRICARE, 187.68,,OUTPCT LIMIT, 228.33,OTHER, 87.35, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35956,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,TRICARE,TRICARE, 23.55,,OUTPCT LIMIT, 34.19,OTHER, 22.94, 52.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35957,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,TRICARE,TRICARE, 45.93,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35958,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,TRICARE,TRICARE, 144.69,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35959,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,TRICARE,TRICARE, 144.69,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35960,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,TRICARE,TRICARE, 63.34,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35961,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,TRICARE,TRICARE, 63.34,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35962,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,TRICARE,TRICARE, 325.10,,OUTPCT LIMIT, 415.63,OTHER, 235.80, 721.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35963,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,TRICARE,TRICARE, 1435.20,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35964,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,TRICARE,TRICARE, 1435.20,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35965,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,TRICARE,TRICARE, 1722.24,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35966,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,TRICARE,TRICARE, 1722.24,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35967,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,TRICARE,TRICARE, 1722.24,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35968,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,TRICARE,TRICARE, 119.77,,OUTPCT LIMIT, 152.82,OTHER, 85.61, 265.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35969,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,TRICARE,TRICARE, 130.84,,OUTPCT LIMIT, 165.98,OTHER, 89.47, 290.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35970,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,TRICARE,TRICARE, 212.09,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35971,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,TRICARE,TRICARE, 212.09,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35972,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,TRICARE,TRICARE, 79.58,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35973,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,TRICARE,TRICARE, 79.58,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35974,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,TRICARE,TRICARE, 252.45,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35975,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,TRICARE,TRICARE, 252.45,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35976,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,TRICARE,TRICARE, 252.45,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35977,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,TRICARE,TRICARE, 72.73,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35978,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,TRICARE,TRICARE, 72.76,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35979,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,TRICARE,TRICARE, 86.74,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35980,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,TRICARE,TRICARE, 86.74,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35981,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,TRICARE,TRICARE, 63.56,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35982,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,TRICARE,TRICARE, 63.56,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35983,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,TRICARE,TRICARE, 67.96,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35984,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,TRICARE,TRICARE, 67.96,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35985,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,TRICARE,TRICARE, 26.28,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35986,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,TRICARE,TRICARE, 26.28,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35987,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,TRICARE,TRICARE, 132.85,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35988,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,TRICARE,TRICARE, 132.85,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35989,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,TRICARE,TRICARE, 75.48,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35990,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,TRICARE,TRICARE, 75.48,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35991,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,TRICARE,TRICARE, 76.18,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35992,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,TRICARE,TRICARE, 76.18,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35993,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,TRICARE,TRICARE, 38.84,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35994,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,TRICARE,TRICARE, 38.84,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35995,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,TRICARE,TRICARE, 42.63,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35996,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,TRICARE,TRICARE, 42.63,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35997,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,TRICARE,TRICARE, 46.72,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35998,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,TRICARE,TRICARE, 46.72,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 35999,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,TRICARE,TRICARE, 46.72,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36000,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,TRICARE,TRICARE, 185.47,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36001,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,TRICARE,TRICARE, 59.55,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36002,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,TRICARE,TRICARE, 59.55,,OUTPCT LIMIT, 72.71,OTHER, 28.82, 132.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36003,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,TRICARE,TRICARE, 54.26,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36004,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,TRICARE,TRICARE, 54.23,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36005,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,TRICARE,TRICARE, 54.26,,OUTPCT LIMIT, 74.35,OTHER, 52.84, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36006,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,TRICARE,TRICARE, 57.88,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36007,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,TRICARE,TRICARE, 57.88,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36008,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,TRICARE,TRICARE, 57.88,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36009,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,TRICARE,TRICARE, 42.01,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36010,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,TRICARE,TRICARE, 42.01,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36011,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,TRICARE,TRICARE, 29.86,,OUTPCT LIMIT, 47.68,OTHER, 29.08, 66.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36012,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,TRICARE,TRICARE, 79.05,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36013,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,TRICARE,TRICARE, 79.05,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36014,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,TRICARE,TRICARE, 79.05,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36015,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,TRICARE,TRICARE, 94.94,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36016,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,TRICARE,TRICARE, 94.94,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36017,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,TRICARE,TRICARE, 94.94,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36018,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,TRICARE,TRICARE, 54.17,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36019,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,TRICARE,TRICARE, 54.17,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36020,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,TRICARE,TRICARE, 54.17,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36021,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,TRICARE,TRICARE, 19.43,,OUTPCT LIMIT, 30.33,OTHER, 18.92, 43.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36022,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,TRICARE,TRICARE, 117.04,,OUTPCT LIMIT, 178.52,OTHER, 113.97, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36023,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,TRICARE,TRICARE, 138.88,,OUTPCT LIMIT, 202.67,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36024,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,TRICARE,TRICARE, 131.50,,OUTPCT LIMIT, 194.50,OTHER, 128.04, 291.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36025,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,TRICARE,TRICARE, 65.52,,OUTPCT LIMIT, 106.37,OTHER, 63.79, 145.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36026,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,TRICARE,TRICARE, 112.31,,OUTPCT LIMIT, 173.75,OTHER, 109.36, 249.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36027,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,TRICARE,TRICARE, 118.72,,OUTPCT LIMIT, 180.83,OTHER, 115.60, 263.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36028,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,TRICARE,TRICARE, 140.12,,OUTPCT LIMIT, 204.49,OTHER, 136.43, 310.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36029,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,TRICARE,TRICARE, 67.67,,OUTPCT LIMIT, 108.91,OTHER, 65.89, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36030,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,TRICARE,TRICARE, 53.31,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36031,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,TRICARE,TRICARE, 53.31,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36032,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,TRICARE,TRICARE, 53.31,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36033,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,TRICARE,TRICARE, 32.41,,OUTPCT LIMIT, 44.69,OTHER, 31.56, 71.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36034,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,TRICARE,TRICARE, 56.37,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36035,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,TRICARE,TRICARE, 56.37,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36036,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,TRICARE,TRICARE, 39.13,,OUTPCT LIMIT, 59.17,OTHER, 38.11, 86.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36037,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,TRICARE,TRICARE, 51.23,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36038,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,TRICARE,TRICARE, 51.23,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36039,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,TRICARE,TRICARE, 51.23,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36040,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,TRICARE,TRICARE, 12.81,,OUTPCT LIMIT, 68.90,OTHER, 12.81, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36041,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,TRICARE,TRICARE, 63.48,,OUTPCT LIMIT, 93.12,OTHER, 61.82, 140.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36042,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,TRICARE,TRICARE, 53.43,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36043,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,TRICARE,TRICARE, 117.04,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36044,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,TRICARE,TRICARE, 54.76,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36045,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,TRICARE,TRICARE, 54.76,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36046,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,TRICARE,TRICARE, 54.76,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36047,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,TRICARE,TRICARE, 33.12,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36048,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,TRICARE,TRICARE, 45.93,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36049,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,TRICARE,TRICARE, 62.27,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36050,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,TRICARE,TRICARE, 45.93,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36051,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,TRICARE,TRICARE, 62.27,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36052,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,TRICARE,TRICARE, 33.12,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36053,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,TRICARE,TRICARE, 33.12,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36054,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,TRICARE,TRICARE, 132.48,,OUTPCT LIMIT, 192.27,OTHER, 129.00, 294.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36055,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36056,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36057,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,TRICARE,TRICARE, 106.69,,OUTPCT LIMIT, 145.27,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36058,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,TRICARE,TRICARE, 65.69,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36059,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,TRICARE,TRICARE, 65.69,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36060,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,TRICARE,TRICARE, 111.31,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36061,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,TRICARE,TRICARE, 111.31,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36062,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,TRICARE,TRICARE, 174.17,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36063,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,TRICARE,TRICARE, 174.17,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36064,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,TRICARE,TRICARE, 216.96,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36065,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,TRICARE,TRICARE, 216.96,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36066,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,TRICARE,TRICARE, 21.02,,OUTPCT LIMIT, 30.51,OTHER, 20.47, 46.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36067,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,TRICARE,TRICARE, 45.79,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36068,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,TRICARE,TRICARE, 45.79,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36069,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,TRICARE,TRICARE, 76.57,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36070,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,TRICARE,TRICARE, 76.57,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36071,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,TRICARE,TRICARE, 112.98,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36072,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,TRICARE,TRICARE, 112.98,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36073,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,TRICARE,TRICARE, 151.27,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36074,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,TRICARE,TRICARE, 151.27,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36075,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,TRICARE,TRICARE, 150.14,,OUTPCT LIMIT, 272.06,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36076,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,TRICARE,TRICARE, 185.91,,OUTPCT LIMIT, 336.87,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36077,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,TRICARE,TRICARE, 64.03,,OUTPCT LIMIT, 111.61,OTHER, 64.03, 142.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36078,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,TRICARE,TRICARE, 78.16,,OUTPCT LIMIT, 149.82,OTHER, 78.16, 173.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36079,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,TRICARE,TRICARE, 113.05,,OUTPCT LIMIT, 220.11,OTHER, 113.05, 250.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36080,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,TRICARE,TRICARE, 118.76,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36081,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,TRICARE,TRICARE, 118.76,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36082,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,TRICARE,TRICARE, 110.84,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36083,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,TRICARE,TRICARE, 110.84,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36084,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,TRICARE,TRICARE, 183.71,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36085,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,TRICARE,TRICARE, 183.71,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36086,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,TRICARE,TRICARE, 130.71,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36087,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,TRICARE,TRICARE, 130.71,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36088,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,TRICARE,TRICARE, 290.28,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36089,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,TRICARE,TRICARE, 290.28,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36090,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,TRICARE,TRICARE, 150.14,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36091,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,TRICARE,TRICARE, 150.14,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36092,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,TRICARE,TRICARE, 455.32,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36093,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,TRICARE,TRICARE, 455.32,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36094,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,TRICARE,TRICARE, 185.91,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36095,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,TRICARE,TRICARE, 185.91,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36096,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,TRICARE,TRICARE, 759.45,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36097,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,TRICARE,TRICARE, 759.45,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36098,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,TRICARE,TRICARE, 221.24,,OUTPCT LIMIT, 429.06,OTHER, 221.24, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36099,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,TRICARE,TRICARE, 1214.74,,OUTPCT LIMIT, 1514.86,OTHER, 720.78, 2695.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36100,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,TRICARE,TRICARE, 445.31,,OUTPCT LIMIT, 646.30,OTHER, 433.62, 988.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36101,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,TRICARE,TRICARE, 13.25,,OUTPCT LIMIT, 19.23,OTHER, 12.90, 29.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36102,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,TRICARE,TRICARE, 73.95,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36103,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,TRICARE,TRICARE, 73.95,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36104,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,TRICARE,TRICARE, 116.36,,OUTPCT LIMIT, 167.97,OTHER, 113.31, 258.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36105,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,TRICARE,TRICARE, 121.24,,OUTPCT LIMIT, 173.37,OTHER, 118.06, 269.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36106,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,TRICARE,TRICARE, 126.50,,OUTPCT LIMIT, 179.18,OTHER, 123.17, 280.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36107,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,TRICARE,TRICARE, 143.01,,OUTPCT LIMIT, 197.44,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36108,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,TRICARE,TRICARE, 138.88,,OUTPCT LIMIT, 192.88,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36109,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,TRICARE,TRICARE, 160.28,,OUTPCT LIMIT, 232.62,OTHER, 156.07, 355.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36110,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,TRICARE,TRICARE, 174.17,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36111,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,TRICARE,TRICARE, 104.73,,OUTPCT LIMIT, 155.10,OTHER, 101.97, 232.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36112,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,TRICARE,TRICARE, 111.86,,OUTPCT LIMIT, 162.99,OTHER, 108.92, 248.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36113,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,TRICARE,TRICARE, 121.99,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36114,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,TRICARE,TRICARE, 121.99,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36115,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,TRICARE,TRICARE, 121.99,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36116,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,TRICARE,TRICARE, 124.62,,OUTPCT LIMIT, 177.10,OTHER, 121.35, 276.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36117,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,TRICARE,TRICARE, 132.88,,OUTPCT LIMIT, 192.85,OTHER, 129.39, 294.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36118,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,TRICARE,TRICARE, 143.01,,OUTPCT LIMIT, 207.56,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36119,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,TRICARE,TRICARE, 38.29,,OUTPCT LIMIT, 55.57,OTHER, 37.28, 84.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36120,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,TRICARE,TRICARE, 65.69,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36121,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,TRICARE,TRICARE, 30.91,,OUTPCT LIMIT, 44.86,OTHER, 30.10, 68.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36122,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,TRICARE,TRICARE, 117.49,,OUTPCT LIMIT, 170.52,OTHER, 114.40, 260.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36123,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,TRICARE,TRICARE, 23.35,,OUTPCT LIMIT, 33.14,OTHER, 22.74, 51.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36124,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,TRICARE,TRICARE, 28.90,,OUTPCT LIMIT, 39.28,OTHER, 28.14, 64.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36125,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,TRICARE,TRICARE, 41.68,,OUTPCT LIMIT, 60.49,OTHER, 40.58, 92.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36126,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,TRICARE,TRICARE, 9.72,,OUTPCT LIMIT, 14.10,OTHER, 9.46, 21.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36127,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,TRICARE,TRICARE, 9.72,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36128,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,TRICARE,TRICARE, 65.69,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36129,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,TRICARE,TRICARE, 112.61,,OUTPCT LIMIT, 148.65,OTHER, 101.33, 249.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36130,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,TRICARE,TRICARE, 121.44,,OUTPCT LIMIT, 166.04,OTHER, 118.25, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36131,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,TRICARE,TRICARE, 5.63,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36132,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,TRICARE,TRICARE, 5.63,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36133,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,TRICARE,TRICARE, 170.02,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36134,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,TRICARE,TRICARE, 170.02,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36135,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,TRICARE,TRICARE, 268.05,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36136,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,TRICARE,TRICARE, 268.05,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36137,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,TRICARE,TRICARE, 156.77,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36138,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,TRICARE,TRICARE, 156.77,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36139,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,TRICARE,TRICARE, 226.10,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36140,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,TRICARE,TRICARE, 226.10,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36141,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,TRICARE,TRICARE, 387.72,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36142,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,TRICARE,TRICARE, 387.72,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36143,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,TRICARE,TRICARE, 430.56,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36144,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,TRICARE,TRICARE, 430.56,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36145,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,TRICARE,TRICARE, 60.06,,OUTPCT LIMIT, 87.16,OTHER, 58.48, 133.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36146,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,TRICARE,TRICARE, 28.26,,OUTPCT LIMIT, 41.02,OTHER, 27.52, 62.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36147,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,TRICARE,TRICARE, 33.12,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36148,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,TRICARE,TRICARE, 1323.03,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36149,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,TRICARE,TRICARE, 1323.03,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36150,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,TRICARE,TRICARE, 1440.06,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36151,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,TRICARE,TRICARE, 1440.06,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36152,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,TRICARE,TRICARE, 1015.68,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36153,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,TRICARE,TRICARE, 1015.68,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36154,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,TRICARE,TRICARE, 1015.68,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36155,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,TRICARE,TRICARE, 883.20,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36156,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,TRICARE,TRICARE, 883.20,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36157,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,TRICARE,TRICARE, 883.20,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36158,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,TRICARE,TRICARE, 883.20,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36159,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,TRICARE,TRICARE, 8.45,,OUTPCT LIMIT, 9.74,OTHER, 1.66, 18.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36160,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,TRICARE,TRICARE, 49.75,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36161,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,TRICARE,TRICARE, 2.65,,OUTPCT LIMIT, 11.82,OTHER, 2.58, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36162,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,TRICARE,TRICARE, 39.79,,OUTPCT LIMIT, 57.75,OTHER, 38.74, 88.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36163,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,TRICARE,TRICARE, 20.64,,OUTPCT LIMIT, 29.96,OTHER, 20.10, 45.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36164,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,TRICARE,TRICARE, 73.00,,OUTPCT LIMIT, 88.75,OTHER, 33.71, 162.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36165,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,TRICARE,TRICARE, 45.93,,OUTPCT LIMIT, 58.81,OTHER, 33.71, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36166,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,TRICARE,TRICARE, 172.67,,OUTPCT LIMIT, 250.60,OTHER, 168.13, 383.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36167,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,TRICARE,TRICARE, 174.17,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36168,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,TRICARE,TRICARE, 174.17,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36169,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,TRICARE,TRICARE, 18.77,,OUTPCT LIMIT, 35.44,OTHER, 18.28, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36170,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,TRICARE,TRICARE, 27.03,,OUTPCT LIMIT, 44.57,OTHER, 26.32, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36171,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,TRICARE,TRICARE, 30.03,,OUTPCT LIMIT, 43.58,OTHER, 29.24, 66.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36172,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36173,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,TRICARE,TRICARE, 114.73,,OUTPCT LIMIT, 166.51,OTHER, 111.71, 254.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36174,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,TRICARE,TRICARE, 41.41,,OUTPCT LIMIT, 60.10,OTHER, 40.32, 91.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36175,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,TRICARE,TRICARE, 3.39,,OUTPCT LIMIT, 4.92,OTHER, 3.30, 7.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36176,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,TRICARE,TRICARE, 3.29,,OUTPCT LIMIT, 4.77,OTHER, 3.20, 7.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36177,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,TRICARE,TRICARE, 8.97,,OUTPCT LIMIT, 13.02,OTHER, 8.74, 19.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36178,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,TRICARE,TRICARE, 92.74,,OUTPCT LIMIT, 134.59,OTHER, 90.30, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36179,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,TRICARE,TRICARE, .94,,OUTPCT LIMIT, 1.36,OTHER, .91, 2.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36180,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,TRICARE,TRICARE, 1.45,,OUTPCT LIMIT, 2.10,OTHER, 1.41, 3.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36181,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,TRICARE,TRICARE, 17.85,,OUTPCT LIMIT, 25.91,OTHER, 17.38, 39.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36182,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,TRICARE,TRICARE, 64.08,,OUTPCT LIMIT, 93.00,OTHER, 62.40, 142.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36183,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,TRICARE,TRICARE, 1.01,,OUTPCT LIMIT, 1.46,OTHER, .98, 2.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36184,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,TRICARE,TRICARE, .71,,OUTPCT LIMIT, 1.03,OTHER, .69, 1.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36185,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,TRICARE,TRICARE, 3.55,,OUTPCT LIMIT, 5.15,OTHER, 3.46, 7.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36186,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,TRICARE,TRICARE, 7.90,,OUTPCT LIMIT, 11.46,OTHER, 7.69, 17.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36187,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,TRICARE,TRICARE, 3.02,,OUTPCT LIMIT, 4.38,OTHER, 2.94, 6.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36188,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,TRICARE,TRICARE, 1.77,,OUTPCT LIMIT, 2.56,OTHER, 1.72, 3.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36189,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,TRICARE,TRICARE, 5.16,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36190,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,TRICARE,TRICARE, 5.74,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36191,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,TRICARE,TRICARE, 30.17,,OUTPCT LIMIT, 43.79,OTHER, 29.38, 66.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36192,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,TRICARE,TRICARE, 15.86,,OUTPCT LIMIT, 23.02,OTHER, 15.45, 35.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36193,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,TRICARE,TRICARE, 4.65,,OUTPCT LIMIT, 6.74,OTHER, 4.52, 10.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36194,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,TRICARE,TRICARE, 3.59,,OUTPCT LIMIT, 5.20,OTHER, 3.49, 7.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36195,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,TRICARE,TRICARE, 176.20,,OUTPCT LIMIT, 575.18,OTHER, 171.57, 1597.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36196,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,TRICARE,TRICARE, 176.20,,OUTPCT LIMIT, 690.66,OTHER, 171.57, 2082.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36197,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,TRICARE,TRICARE, 176.20,,OUTPCT LIMIT, 656.15,OTHER, 171.57, 1937.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36198,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,TRICARE,TRICARE, 176.20,,OUTPCT LIMIT, 607.70,OTHER, 171.57, 1734.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36199,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,TRICARE,TRICARE, 220.36,,OUTPCT LIMIT, 735.35,OTHER, 214.57, 2065.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36200,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,TRICARE,TRICARE, 377.57,,OUTPCT LIMIT, 421.89,OTHER, 18.42, 837.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36201,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,TRICARE,TRICARE, 2.12,,OUTPCT LIMIT, 3.08,OTHER, 2.06, 4.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36202,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,TRICARE,TRICARE, 153.68,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36203,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,TRICARE,TRICARE, 153.68,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36204,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,TRICARE,TRICARE, 153.68,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36205,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,TRICARE,TRICARE, 153.68,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36206,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,TRICARE,TRICARE, 153.68,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36207,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,TRICARE,TRICARE, 153.68,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36208,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,TRICARE,TRICARE, 153.68,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36209,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,TRICARE,TRICARE, 153.68,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36210,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,TRICARE,TRICARE, 153.68,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36211,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,TRICARE,TRICARE, 153.68,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36212,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,TRICARE,TRICARE, 153.68,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36213,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,TRICARE,TRICARE, 153.68,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36214,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,TRICARE,TRICARE, 183.26,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36215,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,TRICARE,TRICARE, 183.26,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36216,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,TRICARE,TRICARE, 183.26,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36217,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,TRICARE,TRICARE, 183.26,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36218,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36219,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36220,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36221,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36222,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36223,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36224,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36225,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36226,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36227,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36228,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36229,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36230,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36231,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36232,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36233,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36234,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36235,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36236,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36237,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,TRICARE,TRICARE, 585.56,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36238,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,TRICARE,TRICARE, 46.92,,OUTPCT LIMIT, 62.01,OTHER, 42.53, 104.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36239,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,TRICARE,TRICARE, 50.34,,OUTPCT LIMIT, 73.06,OTHER, 49.02, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36240,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,TRICARE,TRICARE, 44.16,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36241,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,TRICARE,TRICARE, 220.80,,OUTPCT LIMIT, 320.46,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36242,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,TRICARE,TRICARE, 18.55,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36243,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,TRICARE,TRICARE, 1.32,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36244,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,TRICARE,TRICARE, 15.46,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36245,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,TRICARE,TRICARE, 1.32,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36246,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,TRICARE,TRICARE, 11.92,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36247,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,TRICARE,TRICARE, 1.32,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36248,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,TRICARE,TRICARE, 6.62,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36249,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,TRICARE,TRICARE, 1.39,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36250,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,TRICARE,TRICARE, 33.12,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36251,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,TRICARE,TRICARE, 1.39,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36252,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,TRICARE,TRICARE, 2.00,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36253,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,TRICARE,TRICARE, 44.60,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36254,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,TRICARE,TRICARE, 2.65,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36255,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,TRICARE,TRICARE, 2.65,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36256,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,TRICARE,TRICARE, 81.22,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36257,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,TRICARE,TRICARE, 2.65,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36258,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,TRICARE,TRICARE, 79.49,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36259,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,TRICARE,TRICARE, 25.61,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36260,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,TRICARE,TRICARE, 25.61,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36261,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,TRICARE,TRICARE, 146.68,,OUTPCT LIMIT, 212.89,OTHER, 142.83, 325.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36262,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,TRICARE,TRICARE, 53.78,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36263,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,TRICARE,TRICARE, 33.12,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36264,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,TRICARE,TRICARE, 434.81,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36265,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,TRICARE,TRICARE, 316.64,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36266,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,TRICARE,TRICARE, 3.97,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36267,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,TRICARE,TRICARE, 2.65,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36268,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,TRICARE,TRICARE, 44.60,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36269,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,TRICARE,TRICARE, 44.60,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36270,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,TRICARE,TRICARE, 44.60,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36271,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,TRICARE,TRICARE, 44.60,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36272,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,TRICARE,TRICARE, 44.60,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36273,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,TRICARE,TRICARE, 44.60,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36274,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,TRICARE,TRICARE, 44.60,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36275,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,TRICARE,TRICARE, 2.65,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36276,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,TRICARE,TRICARE, 44.60,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36277,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,TRICARE,TRICARE, 45.04,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36278,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,TRICARE,TRICARE, 31.72,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36279,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,TRICARE,TRICARE, 31.72,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36280,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,TRICARE,TRICARE, 33.12,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36281,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,TRICARE,TRICARE, 60.76,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36282,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,TRICARE,TRICARE, 1.32,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36283,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,TRICARE,TRICARE, 6.62,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36284,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,TRICARE,TRICARE, 6.62,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36285,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,TRICARE,TRICARE, 6.62,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36286,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,TRICARE,TRICARE, 7.95,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36287,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,TRICARE,TRICARE, 10.60,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36288,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,TRICARE,TRICARE, 1.32,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36289,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,TRICARE,TRICARE, 12.59,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36290,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,TRICARE,TRICARE, 12.59,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36291,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,TRICARE,TRICARE, 13.25,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36292,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,TRICARE,TRICARE, 13.25,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36293,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,TRICARE,TRICARE, 13.25,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36294,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,TRICARE,TRICARE, 13.25,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36295,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,TRICARE,TRICARE, 1.32,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36296,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,TRICARE,TRICARE, 1.32,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36297,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,TRICARE,TRICARE, 20.53,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36298,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,TRICARE,TRICARE, 4.42,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36299,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,TRICARE,TRICARE, 1.39,,OUTPCT LIMIT, 2.02,OTHER, 1.35, 3.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36300,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,TRICARE,TRICARE, 221.24,,OUTPCT LIMIT, 321.10,OTHER, 215.43, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36301,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,TRICARE,TRICARE, 252.60,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36302,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36303,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36304,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36305,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36306,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36307,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36308,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36309,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,TRICARE,TRICARE, 15.03,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36310,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,TRICARE,TRICARE, 67.21,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36311,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,TRICARE,TRICARE, 62.99,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36312,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,TRICARE,TRICARE, 41.15,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36313,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,TRICARE,TRICARE, 37.77,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36314,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,TRICARE,TRICARE, 114.94,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36315,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,TRICARE,TRICARE, 3358.68,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36316,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,TRICARE,TRICARE, 19.97,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36317,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,TRICARE,TRICARE, 786.05,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36318,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,TRICARE,TRICARE, 786.05,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36319,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,TRICARE,TRICARE, 786.05,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36320,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,TRICARE,TRICARE, 786.05,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36321,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,TRICARE,TRICARE, 786.05,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36322,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,TRICARE,TRICARE, 786.05,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36323,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,TRICARE,TRICARE, 1059.84,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36324,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,TRICARE,TRICARE, 786.05,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36325,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,TRICARE,TRICARE, 786.05,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36326,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,TRICARE,TRICARE, 786.05,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36327,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,TRICARE,TRICARE, 786.05,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36328,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,TRICARE,TRICARE, 786.05,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36329,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,TRICARE,TRICARE, 786.05,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36330,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,TRICARE,TRICARE, 618.24,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36331,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,TRICARE,TRICARE, 618.24,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36332,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,TRICARE,TRICARE, 618.24,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36333,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36334,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36335,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36336,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,TRICARE,TRICARE, 46.37,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36337,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36338,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,TRICARE,TRICARE, 29.64,,OUTPCT LIMIT, 43.03,OTHER, 28.87, 65.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36339,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,TRICARE,TRICARE, 4.42,,OUTPCT LIMIT, 6.41,OTHER, 4.30, 9.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36340,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,TRICARE,TRICARE, 2561.28,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36341,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,TRICARE,TRICARE, 2119.68,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36342,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,TRICARE,TRICARE, 2119.68,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36343,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,TRICARE,TRICARE, 2119.68,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36344,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36345,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36346,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,TRICARE,TRICARE, 192.54,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36347,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,TRICARE,TRICARE, 129.93,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36348,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,TRICARE,TRICARE, 133.94,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36349,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,TRICARE,TRICARE, 109.12,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36350,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,TRICARE,TRICARE, 121.24,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36351,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,TRICARE,TRICARE, 250.39,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36352,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,TRICARE,TRICARE, 76.57,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36353,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,TRICARE,TRICARE, 44.60,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36354,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,TRICARE,TRICARE, 44.89,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36355,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,TRICARE,TRICARE, 65.69,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36356,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,TRICARE,TRICARE, 7.51,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36357,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,TRICARE,TRICARE, 12.36,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36358,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36359,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36360,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36361,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36362,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36363,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36364,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36365,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36366,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36367,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36368,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36369,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36370,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,TRICARE,TRICARE, 143.52,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36371,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,TRICARE,TRICARE, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 36372,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36373,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36374,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36375,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36376,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36377,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36378,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36379,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36380,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36381,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36382,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36383,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36384,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36385,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36386,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36387,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36388,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36389,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36390,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 271.70,OTHER, 142.76, 477.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36391,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 271.70,OTHER, 142.76, 477.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36392,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 168.89,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36393,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 171.36,OTHER, 103.33, 229.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36394,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 273.87,OTHER, 142.76, 481.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36395,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 276.81,OTHER, 142.76, 430.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36396,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 274.44,,CLAIM ADJUSTMENT 3, 242.16,OTHER, 155.70, 354.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36397,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 850.02,OTHER, 203.58, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36398,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1237.88,,CLAIM ADJUSTMENT 3, 667.92,OTHER, 193.86, 1237.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36399,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 274.44,,CLAIM ADJUSTMENT 3, 177.23,OTHER, 68.01, 274.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36400,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 267.92,,CLAIM ADJUSTMENT 3, 131.69,OTHER, 30.91, 267.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36401,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 116.49,OTHER, 56.08, 143.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36402,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 256.74,,CLAIM ADJUSTMENT 3, 405.48,OTHER, 256.74, 597.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36403,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36404,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 256.74,,CLAIM ADJUSTMENT 3, 216.69,OTHER, 107.31, 256.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36405,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36406,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 456.98,,CLAIM ADJUSTMENT 3, 233.68,OTHER, 60.50, 456.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36407,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 158.67,OTHER, 92.29, 204.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36408,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 112.58,OTHER, 70.21, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36409,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 125.44,OTHER, 81.25, 180.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36410,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 114.17,OTHER, 51.67, 151.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36411,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 122.15,OTHER, 60.94, 143.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36412,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 138.81,OTHER, 86.20, 205.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36413,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 117.21,OTHER, 74.19, 164.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36414,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 258.26,OTHER, 90.53, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36415,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 287.58,OTHER, 115.70, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36416,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 334.39,OTHER, 155.88, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36417,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 1514.68,OTHER, 804.50, 2338.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36418,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 1306.30,OTHER, 595.28, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36419,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 925.64,OTHER, 268.49, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36420,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 389.69,OTHER, 87.88, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36421,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 427.24,OTHER, 120.12, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36422,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 457.59,OTHER, 146.17, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36423,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 732.74,OTHER, 102.89, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36424,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1168.49,OTHER, 299.85, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36425,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 300.44,OTHER, 126.74, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36426,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 495.14,OTHER, 178.41, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36427,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 534.75,OTHER, 212.41, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36428,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 572.81,OTHER, 245.09, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36429,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 541.95,OTHER, 218.59, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36430,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 578.99,OTHER, 250.39, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36431,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 1505.88,OTHER, 766.62, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36432,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 646.89,OTHER, 308.68, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36433,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1242.56,OTHER, 363.44, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36434,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 513.14,OTHER, 193.86, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36435,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 520.86,OTHER, 200.49, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36436,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 694.73,OTHER, 349.75, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36437,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 947.76,OTHER, 287.48, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36438,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1393.28,OTHER, 492.83, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36439,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 56.01,OTHER, 24.73, 76.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36440,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 185.53,OTHER, 86.20, 331.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36441,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 97.29,OTHER, 57.09, 126.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36442,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 97.14,OTHER, 56.97, 126.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36443,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 57.02,OTHER, 22.52, 86.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36444,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 372.97,OTHER, 189.00, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36445,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1446.78,OTHER, 538.75, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36446,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1121.68,OTHER, 259.66, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36447,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 383.22,,CLAIM ADJUSTMENT 3, 278.63,OTHER, 165.01, 383.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36448,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 383.22,,CLAIM ADJUSTMENT 3, 427.61,OTHER, 296.20, 675.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36449,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 237.66,OTHER, 143.26, 408.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36450,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 253.66,OTHER, 143.26, 440.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36451,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 272.17,OTHER, 143.26, 477.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36452,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 251.39,OTHER, 143.26, 436.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36453,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 261.55,OTHER, 143.26, 400.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36454,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 264.56,OTHER, 143.26, 462.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36455,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 306.35,OTHER, 204.98, 467.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36456,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 548.12,OTHER, 309.01, 833.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36457,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 132.82,,CLAIM ADJUSTMENT 3, 300.52,OTHER, 132.82, 482.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36458,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 132.82,,CLAIM ADJUSTMENT 3, 293.08,OTHER, 132.82, 524.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36459,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 1023.77,OTHER, 309.01, 1906.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36460,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 498.22,OTHER, 309.01, 738.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36461,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 435.32,,CLAIM ADJUSTMENT 3, 1703.49,OTHER, 435.32, 3210.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36462,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 435.32,,CLAIM ADJUSTMENT 3, 601.46,OTHER, 382.87, 849.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36463,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2347.12,,CLAIM ADJUSTMENT 3, 2228.68,OTHER, 1193.64, 2648.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36464,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 2329.49,OTHER, 1296.54, 2877.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36465,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 274.44,,CLAIM ADJUSTMENT 3, 163.86,OTHER, 56.52, 274.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36466,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 200.99,OTHER, 145.30, 331.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36467,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 93.03,OTHER, 53.43, 118.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36468,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 43.50,,CLAIM ADJUSTMENT 3, 22.22,OTHER, 5.74, 43.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36469,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 224.77,OTHER, 146.61, 325.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36470,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 451.07,,CLAIM ADJUSTMENT 3, 251.63,OTHER, 77.72, 451.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36471,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2427.54,,CLAIM ADJUSTMENT 3, 1148.36,OTHER, 241.56, 2427.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36472,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2427.54,,CLAIM ADJUSTMENT 3, 1534.16,OTHER, 572.76, 2427.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36473,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 232.01,OTHER, 122.32, 271.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36474,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 124.43,OTHER, 57.02, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36475,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 120.23,OTHER, 53.32, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36476,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 130.25,OTHER, 62.14, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36477,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 130.25,OTHER, 62.14, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36478,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 5204.99,OTHER, 2293.79, 8355.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36479,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 932.84,OTHER, 274.68, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36480,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 424.57,OTHER, 162.56, 774.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36481,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 334.89,OTHER, 162.56, 594.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36482,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 470.23,,CLAIM ADJUSTMENT 3, 675.88,OTHER, 470.23, 1131.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36483,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 499.77,OTHER, 162.56, 925.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36484,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 499.77,OTHER, 162.56, 925.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36485,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 207.69,OTHER, 148.80, 339.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36486,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 207.69,OTHER, 148.80, 339.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36487,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 103.34,,CLAIM ADJUSTMENT 3, 176.70,OTHER, 103.34, 305.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36488,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 188.66,,CLAIM ADJUSTMENT 3, 596.69,OTHER, 188.66, 1107.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36489,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 188.66,,CLAIM ADJUSTMENT 3, 596.69,OTHER, 188.66, 1107.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36490,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 544.52,,CLAIM ADJUSTMENT 3, 1089.64,OTHER, 544.52, 1926.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36491,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36492,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36493,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36494,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36495,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36496,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36497,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 20.38,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36498,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36499,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 331.58,,CLAIM ADJUSTMENT 3, 579.04,OTHER, 331.58, 1003.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36500,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1095.12,,CLAIM ADJUSTMENT 3, 1525.88,OTHER, 974.17, 2161.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36501,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2484.68,,CLAIM ADJUSTMENT 3, 4097.24,OTHER, 2484.68, 6115.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36502,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2985.38,,CLAIM ADJUSTMENT 3, 4480.28,OTHER, 2930.90, 6504.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36503,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1095.12,,CLAIM ADJUSTMENT 3, 813.44,OTHER, 362.55, 1095.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36504,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1095.12,,CLAIM ADJUSTMENT 3, 4090.68,OTHER, 1095.12, 7048.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36505,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.22,,CLAIM ADJUSTMENT 3, 124.21,OTHER, 26.22, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36506,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.22,,CLAIM ADJUSTMENT 3, 124.21,OTHER, 26.22, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36507,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2414.09,,CLAIM ADJUSTMENT 3, 1187.28,OTHER, 279.09, 2414.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36508,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1685.72,,CLAIM ADJUSTMENT 3, 803.17,OTHER, 172.67, 1685.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36509,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1685.72,,CLAIM ADJUSTMENT 3, 1733.21,OTHER, 971.08, 2155.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36510,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 1757.99,OTHER, 857.80, 2765.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36511,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 477.65,OTHER, 147.05, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36512,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 497.71,OTHER, 164.28, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36513,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 1514.68,OTHER, 857.80, 2302.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36514,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 2013.65,OTHER, 857.80, 3252.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36515,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 549.67,OTHER, 208.88, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36516,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 578.48,OTHER, 233.61, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36517,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36518,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36519,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 625.15,,CLAIM ADJUSTMENT 3, 718.33,OTHER, 501.48, 1142.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36520,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36521,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2666.24,,CLAIM ADJUSTMENT 3, 1780.93,OTHER, 711.42, 2666.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36522,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4593.88,,CLAIM ADJUSTMENT 3, 2411.76,OTHER, 661.96, 4593.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36523,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 566.36,,CLAIM ADJUSTMENT 3, 283.55,OTHER, 69.77, 566.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36524,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 566.36,,CLAIM ADJUSTMENT 3, 298.98,OTHER, 83.02, 566.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36525,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 906.71,,CLAIM ADJUSTMENT 3, 482.77,OTHER, 136.45, 906.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36526,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 603.90,OTHER, 244.65, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36527,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 652.77,OTHER, 286.60, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36528,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 754.11,OTHER, 373.59, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36529,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 716.04,OTHER, 340.92, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36530,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 701.64,OTHER, 328.55, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36531,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1148.80,,CLAIM ADJUSTMENT 3, 2366.55,OTHER, 1148.80, 3726.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36532,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1384.25,,CLAIM ADJUSTMENT 3, 623.49,OTHER, 110.84, 1384.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36533,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 198.06,,CLAIM ADJUSTMENT 3, 256.43,OTHER, 159.42, 353.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36534,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1384.25,,CLAIM ADJUSTMENT 3, 637.38,OTHER, 122.76, 1384.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36535,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2350.90,,CLAIM ADJUSTMENT 3, 982.61,OTHER, 122.76, 2350.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36536,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2085.61,,CLAIM ADJUSTMENT 3, 1507.20,OTHER, 654.45, 2085.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36537,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3410.78,,CLAIM ADJUSTMENT 3, 3143.54,OTHER, 1652.91, 3668.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36538,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4593.88,,CLAIM ADJUSTMENT 3, 2486.35,OTHER, 725.99, 4593.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36539,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4593.88,,CLAIM ADJUSTMENT 3, 2559.90,OTHER, 789.14, 4593.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36540,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36541,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 539.71,,CLAIM ADJUSTMENT 3, 1667.02,OTHER, 539.71, 2808.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36542,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3135.31,,CLAIM ADJUSTMENT 3, 1786.42,OTHER, 572.31, 3135.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36543,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5153.51,,CLAIM ADJUSTMENT 3, 3662.54,OTHER, 1564.15, 5153.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36544,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1963.90,,CLAIM ADJUSTMENT 3, 889.66,OTHER, 161.63, 1963.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36545,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 191.60,,CLAIM ADJUSTMENT 3, 242.39,OTHER, 173.27, 394.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36546,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 191.60,,CLAIM ADJUSTMENT 3, 242.39,OTHER, 173.27, 394.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36547,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2085.61,,CLAIM ADJUSTMENT 3, 2146.09,OTHER, 1202.92, 2669.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36548,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 377.59,,CLAIM ADJUSTMENT 3, 199.77,OTHER, 96.75, 377.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36549,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 657.86,,CLAIM ADJUSTMENT 3, 266.50,OTHER, 96.75, 657.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36550,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1965.95,,CLAIM ADJUSTMENT 3, 2146.91,OTHER, 1478.34, 3369.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36551,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1965.95,,CLAIM ADJUSTMENT 3, 2146.91,OTHER, 1478.34, 3369.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36552,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36553,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36554,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36555,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4781.78,,CLAIM ADJUSTMENT 3, 2579.17,OTHER, 748.07, 4781.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36556,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 146.68,,CLAIM ADJUSTMENT 3, 162.43,OTHER, 112.28, 255.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36557,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 146.68,,CLAIM ADJUSTMENT 3, 145.32,OTHER, 97.21, 221.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36558,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 191.60,,CLAIM ADJUSTMENT 3, 116.13,OTHER, 62.09, 191.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36559,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 76.24,OTHER, 51.17, 116.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36560,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 124.60,OTHER, 86.34, 208.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36561,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36562,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 62.55,OTHER, 36.98, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36563,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36564,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 99.80,OTHER, 58.91, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36565,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36566,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 161.46,OTHER, 113.20, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36567,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36568,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 62.55,OTHER, 36.98, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36569,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36570,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 171.96,OTHER, 122.45, 279.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36571,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36572,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 127.74,OTHER, 86.34, 215.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36573,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36574,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 189.58,OTHER, 137.97, 314.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36575,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36576,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 116.92,OTHER, 84.85, 193.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36577,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36578,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 299.54,OTHER, 138.19, 535.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36579,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36580,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 221.04,OTHER, 138.19, 377.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36581,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36582,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 177.44,OTHER, 127.28, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36583,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36584,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 71.21,OTHER, 44.60, 101.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36585,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36586,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 193.56,OTHER, 86.34, 347.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36587,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36588,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 223.50,OTHER, 86.34, 407.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36589,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1313.91,OTHER, 283.82, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36590,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1313.91,OTHER, 283.82, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36591,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36592,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36593,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1196.04,OTHER, 432.18, 2193.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36594,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1196.04,OTHER, 432.18, 2193.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36595,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36596,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36597,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1545.39,OTHER, 485.27, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36598,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1545.39,OTHER, 485.27, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36599,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36600,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36601,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.20,OTHER, 283.82, 1781.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36602,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36603,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 691.35,OTHER, 432.18, 1180.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36604,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36605,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 887.08,OTHER, 485.27, 1548.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36606,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36607,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 901.22,OTHER, 283.82, 1673.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36608,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 901.22,OTHER, 283.82, 1673.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36609,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36610,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36611,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1055.93,OTHER, 432.18, 1912.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36612,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1302.68,OTHER, 432.18, 2407.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36613,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36614,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36615,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 513.03,OTHER, 350.02, 797.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36616,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36617,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1290.59,OTHER, 283.82, 2454.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36618,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36619,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1374.81,OTHER, 432.18, 2552.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36620,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36621,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1265.96,OTHER, 485.27, 2308.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36622,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36623,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1076.14,OTHER, 495.38, 1923.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36624,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1076.14,OTHER, 495.38, 1923.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36625,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1076.14,OTHER, 495.38, 1923.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36626,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36627,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36628,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36629,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1270.81,OTHER, 495.38, 2313.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36630,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36631,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1681.52,OTHER, 779.04, 3002.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36632,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36633,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1224.87,OTHER, 508.57, 2215.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36634,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36635,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 1324.21,OTHER, 616.91, 2362.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36636,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 438.95,OTHER, 187.68, 616.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36637,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1532.99,OTHER, 779.04, 2704.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36638,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36639,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1233.59,OTHER, 508.57, 2232.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36640,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36641,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 1256.33,OTHER, 616.91, 2226.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36642,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 438.95,OTHER, 187.68, 616.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36643,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1461.09,OTHER, 779.04, 2560.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36644,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36645,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1413.66,OTHER, 508.57, 2594.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36646,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36647,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2181.19,OTHER, 779.04, 4005.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36648,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2181.19,OTHER, 779.04, 4005.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36649,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36650,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36651,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36652,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36653,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36654,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36655,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36656,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36657,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36658,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36659,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36660,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36661,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36662,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36663,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36664,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36665,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 242.05,OTHER, 86.34, 444.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36666,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 243.52,OTHER, 86.34, 447.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36667,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36668,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36669,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 214.14,OTHER, 138.19, 363.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36670,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 240.03,OTHER, 138.19, 415.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36671,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36672,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36673,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 248.87,OTHER, 138.19, 433.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36674,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36675,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 165.10,OTHER, 86.34, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36676,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36677,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 62.55,OTHER, 36.98, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36678,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36679,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1211.40,OTHER, 283.82, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36680,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1211.40,OTHER, 283.82, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36681,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1211.40,OTHER, 283.82, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36682,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36683,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36684,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1356.87,OTHER, 432.18, 2737.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36685,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1356.87,OTHER, 432.18, 2737.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36686,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36687,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1817.25,OTHER, 485.27, 3415.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36688,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36689,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 1171.85,OTHER, 117.71, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36690,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 1171.85,OTHER, 117.71, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36691,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 1171.85,OTHER, 117.71, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36692,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 209.22,OTHER, 117.71, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36693,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 209.22,OTHER, 117.71, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36694,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 209.22,OTHER, 117.71, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36695,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36696,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36697,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36698,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36699,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36700,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36701,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36702,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36703,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36704,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36705,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36706,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36707,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36708,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.01,OTHER, 86.34, 297.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36709,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.01,OTHER, 86.34, 297.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36710,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36711,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36712,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 247.65,OTHER, 138.19, 430.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36713,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36714,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 350.60,OTHER, 138.19, 637.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36715,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36716,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 382.63,OTHER, 138.19, 701.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36717,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36718,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 293.50,OTHER, 138.19, 522.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36719,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36720,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 265.86,OTHER, 138.19, 467.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36721,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36722,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 161.46,OTHER, 113.20, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36723,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36724,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 142.64,OTHER, 86.34, 245.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36725,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36726,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 63.06,OTHER, 36.98, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36727,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 163.44,OTHER, 113.20, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36728,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 96.05,OTHER, 37.54, 146.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36729,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 259.24,OTHER, 138.19, 454.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36730,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36731,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 166.91,OTHER, 118.00, 268.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36732,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36733,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 407.08,OTHER, 138.19, 750.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36734,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36735,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1459.38,OTHER, 283.82, 2793.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36736,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1459.38,OTHER, 283.82, 2793.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36737,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1459.38,OTHER, 283.82, 2793.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36738,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36739,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36740,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36741,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 664.89,OTHER, 483.75, 1102.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36742,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36743,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1649.11,OTHER, 283.82, 3173.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36744,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1649.11,OTHER, 283.82, 3173.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36745,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36746,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36747,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1665.51,OTHER, 432.18, 3136.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36748,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36749,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1439.18,OTHER, 283.82, 2752.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36750,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36751,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1652.58,OTHER, 432.18, 3110.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36752,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36753,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1580.48,OTHER, 485.27, 2940.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36754,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36755,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1712.29,OTHER, 508.57, 3193.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36756,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36757,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1894.78,OTHER, 508.57, 3559.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36758,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36759,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1677.93,OTHER, 508.57, 3124.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36760,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36761,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2119.80,OTHER, 779.04, 3881.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36762,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36763,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2539.54,OTHER, 779.04, 4724.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36764,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36765,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2390.20,OTHER, 779.04, 4424.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36766,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36767,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36768,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36769,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36770,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 236.81,OTHER, 138.19, 409.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36771,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36772,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 193.87,OTHER, 138.19, 323.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36773,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36774,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1261.16,OTHER, 283.82, 2395.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36775,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1261.16,OTHER, 283.82, 2395.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36776,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36777,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36778,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1256.10,OTHER, 432.18, 2314.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36779,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36780,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 894.65,OTHER, 485.27, 1563.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36781,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36782,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1751.53,OTHER, 508.57, 3272.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36783,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36784,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2629.35,OTHER, 779.04, 4904.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36785,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36786,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36787,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36788,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36789,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36790,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36791,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36792,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 164.19,OTHER, 86.34, 288.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36793,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36794,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 224.35,OTHER, 86.34, 408.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36795,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36796,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 208.71,OTHER, 86.34, 377.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36797,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 208.71,OTHER, 86.34, 377.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36798,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 215.71,OTHER, 86.34, 391.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36799,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36800,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36801,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36802,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 149.11,OTHER, 86.34, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36803,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 149.11,OTHER, 86.34, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36804,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 149.11,OTHER, 86.34, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36805,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36806,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36807,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36808,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 175.84,OTHER, 86.34, 311.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36809,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.06,OTHER, 86.34, 298.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36810,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.06,OTHER, 86.34, 298.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36811,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36812,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36813,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36814,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 235.06,OTHER, 138.19, 405.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36815,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 235.06,OTHER, 138.19, 405.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36816,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 240.36,OTHER, 138.19, 416.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36817,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36818,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36819,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36820,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 219.70,OTHER, 86.34, 399.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36821,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 214.45,OTHER, 86.34, 389.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36822,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 214.45,OTHER, 86.34, 389.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36823,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36824,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36825,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36826,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 206.56,OTHER, 86.34, 373.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36827,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 211.81,OTHER, 86.34, 383.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36828,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 206.56,OTHER, 86.34, 373.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36829,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36830,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36831,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36832,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 230.04,OTHER, 86.34, 420.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36833,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 223.50,OTHER, 86.34, 407.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36834,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36835,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36836,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36837,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 230.83,OTHER, 86.34, 421.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36838,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 230.83,OTHER, 86.34, 421.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36839,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 237.37,OTHER, 86.34, 435.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36840,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36841,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36842,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36843,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 99.80,OTHER, 58.91, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36844,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 125.68,OTHER, 81.70, 186.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36845,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 99.80,OTHER, 58.91, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36846,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36847,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36848,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36849,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 213.73,OTHER, 86.34, 387.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36850,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 207.73,OTHER, 86.34, 375.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36851,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 207.74,OTHER, 86.34, 375.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36852,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36853,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36854,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36855,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 238.18,OTHER, 86.34, 436.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36856,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 243.44,OTHER, 86.34, 447.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36857,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 238.18,OTHER, 86.34, 436.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36858,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36859,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36860,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36861,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 238.48,OTHER, 138.19, 412.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36862,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 231.94,OTHER, 138.19, 399.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36863,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 231.94,OTHER, 138.19, 399.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36864,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36865,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36866,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36867,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 220.36,OTHER, 86.34, 400.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36868,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 220.42,OTHER, 86.34, 401.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36869,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 225.67,OTHER, 86.34, 411.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36870,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36871,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36872,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36873,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36874,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 174.69,OTHER, 86.34, 309.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36875,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36876,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36877,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36878,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36879,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36880,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36881,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36882,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36883,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36884,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36885,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36886,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36887,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36888,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36889,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36890,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36891,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36892,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36893,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36894,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36895,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36896,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36897,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36898,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36899,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36900,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1061.06,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36901,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36902,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36903,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36904,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36905,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36906,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36907,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36908,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36909,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36910,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36911,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36912,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36913,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36914,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36915,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36916,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36917,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36918,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36919,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36920,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36921,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36922,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36923,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36924,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36925,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36926,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36927,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36928,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1484.34,OTHER, 432.18, 2772.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36929,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1484.34,OTHER, 432.18, 2772.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36930,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36931,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36932,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36933,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36934,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36935,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36936,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36937,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1055.55,OTHER, 508.57, 1875.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36938,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36939,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1797.05,OTHER, 779.04, 3234.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36940,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1797.05,OTHER, 779.04, 3234.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36941,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1797.05,OTHER, 779.04, 3234.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36942,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36943,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36944,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36945,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36946,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36947,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36948,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36949,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36950,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36951,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36952,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36953,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36954,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36955,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36956,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36957,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36958,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36959,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36960,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36961,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36962,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36963,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36964,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36965,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36966,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36967,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36968,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36969,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36970,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36971,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36972,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36973,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36974,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36975,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36976,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36977,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1450.34,OTHER, 779.04, 2538.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36978,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1450.34,OTHER, 779.04, 2538.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36979,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36980,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36981,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36982,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36983,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36984,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 36985,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 196.99,OTHER, 88.46, 353.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36986,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 196.99,OTHER, 88.46, 353.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36987,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 196.99,OTHER, 88.46, 353.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36988,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36989,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36990,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36991,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36992,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36993,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36994,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36995,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36996,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36997,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36998,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 36999,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37000,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 234.40,OTHER, 146.51, 446.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37001,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 234.40,OTHER, 146.51, 446.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37002,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 96.05,OTHER, 37.54, 146.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37003,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 96.05,OTHER, 37.54, 146.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37004,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 202.98,OTHER, 88.46, 365.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37005,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 202.98,OTHER, 88.46, 365.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37006,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 208.23,OTHER, 88.46, 375.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37007,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37008,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37009,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37010,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 210.73,OTHER, 86.34, 381.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37011,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 204.73,OTHER, 86.34, 369.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37012,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 204.73,OTHER, 86.34, 369.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37013,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37014,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37015,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37016,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 269.16,OTHER, 138.19, 474.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37017,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 274.41,OTHER, 138.19, 484.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37018,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 269.16,OTHER, 138.19, 474.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37019,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37020,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37021,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37022,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 402.07,OTHER, 138.19, 740.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37023,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 395.36,OTHER, 138.19, 727.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37024,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 395.36,OTHER, 138.19, 727.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37025,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37026,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37027,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37028,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 153.37,OTHER, 86.34, 266.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37029,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37030,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 243.07,OTHER, 86.34, 446.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37031,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 237.82,OTHER, 86.34, 436.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37032,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 237.82,OTHER, 86.34, 436.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37033,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37034,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37035,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37036,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 74.90,OTHER, 36.98, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37037,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 74.90,OTHER, 36.98, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37038,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 116.89,OTHER, 73.96, 168.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37039,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37040,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37041,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37042,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 218.95,OTHER, 138.19, 373.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37043,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 218.95,OTHER, 138.19, 373.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37044,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 225.30,OTHER, 138.19, 386.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37045,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37046,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37047,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37048,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 243.37,OTHER, 138.19, 422.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37049,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 236.76,OTHER, 138.19, 409.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37050,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 236.76,OTHER, 138.19, 409.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37051,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37052,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37053,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37054,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 186.56,OTHER, 86.34, 333.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37055,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 186.56,OTHER, 86.34, 333.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37056,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37057,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37058,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 250.19,OTHER, 86.34, 460.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37059,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 244.84,OTHER, 86.34, 450.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37060,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 244.94,OTHER, 86.34, 450.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37061,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37062,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37063,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37064,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 134.33,OTHER, 86.34, 228.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37065,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 134.33,OTHER, 86.34, 228.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37066,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 134.33,OTHER, 86.34, 228.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37067,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37068,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37069,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37070,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37071,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37072,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37073,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37074,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37075,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37076,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37077,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37078,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 179.26,OTHER, 86.34, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37079,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37080,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37081,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37082,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37083,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37084,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37085,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37086,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37087,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37088,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37089,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37090,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37091,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37092,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37093,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37094,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37095,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1193.14,OTHER, 283.82, 2258.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37096,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37097,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37098,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37099,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37100,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37101,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37102,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37103,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37104,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37105,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37106,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37107,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37108,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37109,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37110,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37111,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37112,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37113,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37114,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37115,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37116,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37117,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37118,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37119,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37120,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1435.02,OTHER, 432.18, 2673.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37121,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1428.39,OTHER, 432.18, 2660.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37122,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1428.39,OTHER, 432.18, 2660.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37123,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37124,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37125,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37126,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37127,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37128,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37129,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37130,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37131,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37132,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 796.22,OTHER, 495.38, 1361.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37133,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 796.22,OTHER, 495.38, 1361.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37134,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37135,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37136,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37137,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37138,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37139,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37140,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37141,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37142,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37143,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37144,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37145,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37146,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37147,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37148,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1953.37,OTHER, 779.04, 3547.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37149,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1953.37,OTHER, 779.04, 3547.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37150,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37151,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37152,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37153,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37154,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37155,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37156,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37157,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37158,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37159,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37160,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37161,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37162,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37163,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37164,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37165,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37166,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37167,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37168,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37169,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37170,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37171,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37172,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37173,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37174,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37175,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37176,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37177,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37178,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37179,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37180,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37181,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37182,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37183,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37184,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37185,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37186,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37187,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37188,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37189,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37190,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37191,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37192,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 102.58,OTHER, 71.38, 162.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37193,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 102.58,OTHER, 71.38, 162.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37194,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37195,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37196,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 172.76,,CLAIM ADJUSTMENT 3, 83.13,OTHER, 36.98, 172.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37197,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 172.76,,CLAIM ADJUSTMENT 3, 105.42,OTHER, 37.54, 172.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37198,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 322.43,OTHER, 138.19, 581.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37199,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 322.43,OTHER, 138.19, 581.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37200,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37201,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37202,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1346.03,OTHER, 283.82, 2565.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37203,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37204,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1544.22,OTHER, 432.18, 2892.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37205,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37206,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1743.20,OTHER, 485.27, 3266.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37207,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37208,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 813.20,,CLAIM ADJUSTMENT 3, 3113.75,OTHER, 813.20, 5860.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37209,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 813.20,,CLAIM ADJUSTMENT 3, 473.04,OTHER, 156.77, 813.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37210,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1743.46,OTHER, 495.38, 3262.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37211,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37212,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 2609.45,OTHER, 276.02, 5105.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37213,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 2609.45,OTHER, 276.02, 5105.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37214,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 265.76,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37215,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 265.76,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37216,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 3021.78,OTHER, 426.91, 5860.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37217,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 3021.78,OTHER, 426.91, 5860.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37218,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 319.65,OTHER, 143.52, 426.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37219,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 319.65,OTHER, 143.52, 426.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37220,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 3385.13,OTHER, 475.94, 6566.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37221,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 3385.13,OTHER, 475.94, 6566.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37222,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 3385.13,OTHER, 475.94, 6566.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37223,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 337.16,OTHER, 143.52, 475.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37224,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 337.16,OTHER, 143.52, 475.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37225,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 337.16,OTHER, 143.52, 475.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37226,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1689.68,OTHER, 508.57, 3148.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37227,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1689.68,OTHER, 508.57, 3148.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37228,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37229,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37230,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1837.06,OTHER, 779.04, 3314.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37231,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37232,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37233,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37234,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37235,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37236,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37237,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 371.17,OTHER, 127.36, 684.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37238,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 371.17,OTHER, 127.36, 684.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37239,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 371.17,OTHER, 127.36, 684.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37240,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 89.21,OTHER, 37.54, 127.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37241,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 89.21,OTHER, 37.54, 127.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37242,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37243,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37244,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 248.14,OTHER, 166.15, 378.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37245,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 230.64,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37246,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 429.88,OTHER, 249.71, 743.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37247,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 132.91,OTHER, 37.54, 249.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37248,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1495.57,OTHER, 495.38, 2764.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37249,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1495.57,OTHER, 495.38, 2764.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37250,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37251,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37252,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37253,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37254,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 385.53,OTHER, 141.55, 706.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37255,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 385.53,OTHER, 141.55, 706.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37256,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 385.53,OTHER, 141.55, 706.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37257,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37258,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37259,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37260,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 286.59,OTHER, 90.89, 531.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37261,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37262,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 281.44,OTHER, 133.37, 501.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37263,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 281.44,OTHER, 133.37, 501.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37264,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 281.44,OTHER, 133.37, 501.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37265,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 288.12,OTHER, 133.37, 514.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37266,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37267,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37268,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37269,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37270,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 503.49,OTHER, 141.55, 942.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37271,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37272,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37273,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37274,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37275,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37276,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37277,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37278,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37279,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37280,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37281,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37282,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 163.97,,CLAIM ADJUSTMENT 3, 468.07,OTHER, 163.97, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37283,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 163.97,,CLAIM ADJUSTMENT 3, 200.02,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37284,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37285,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37286,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37287,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37288,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37289,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37290,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37291,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37292,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37293,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37294,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 414.50,OTHER, 141.55, 764.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37295,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37296,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 214.87,OTHER, 133.37, 367.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37297,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 163.37,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37298,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 408.73,OTHER, 141.55, 752.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37299,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37300,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 507.55,OTHER, 141.55, 950.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37301,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37302,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 775.60,OTHER, 90.89, 1513.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37303,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37304,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 290.56,OTHER, 133.37, 519.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37305,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37306,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.77,OTHER, 141.55, 774.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37307,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37308,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 471.58,OTHER, 141.55, 878.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37309,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 471.58,OTHER, 141.55, 878.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37310,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 471.58,OTHER, 141.55, 878.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37311,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37312,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37313,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37314,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 322.12,OTHER, 90.89, 613.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37315,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 322.12,OTHER, 90.89, 613.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37316,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37317,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37318,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 408.48,OTHER, 141.55, 752.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37319,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37320,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 813.95,OTHER, 137.10, 1568.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37321,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 526.64,OTHER, 137.10, 991.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37322,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 526.64,OTHER, 137.10, 991.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37323,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 190.42,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37324,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 190.42,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37325,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 190.42,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37326,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37327,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 300.33,OTHER, 133.37, 539.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37328,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37329,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37330,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37331,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37332,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37333,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37334,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37335,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37336,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37337,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37338,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37339,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37340,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37341,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37342,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37343,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37344,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37345,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37346,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37347,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37348,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37349,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37350,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37351,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37352,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37353,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37354,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37355,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37356,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 34.54,,CLAIM ADJUSTMENT 3, 78.82,OTHER, 21.15, 181.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37357,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37358,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37359,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37360,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37361,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37362,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37363,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37364,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37365,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 281.03,OTHER, 175.87, 480.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37366,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 281.03,OTHER, 175.87, 480.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37367,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 281.03,OTHER, 175.87, 480.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37368,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 198.15,OTHER, 99.36, 230.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37369,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 198.15,OTHER, 99.36, 230.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37370,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37371,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37372,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37373,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37374,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 235.21,OTHER, 81.44, 588.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37375,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 235.21,OTHER, 81.44, 588.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37376,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 235.21,OTHER, 81.44, 588.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37377,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37378,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37379,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37380,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37381,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37382,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37383,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37384,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 116.40,OTHER, 73.53, 167.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37385,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 70.96,OTHER, 18.55, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37386,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 232.03,,CLAIM ADJUSTMENT 3, 414.07,OTHER, 232.03, 720.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37387,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 158.67,OTHER, 84.28, 343.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37388,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 158.67,OTHER, 84.28, 343.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37389,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 59.28,OTHER, 18.55, 105.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37390,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 59.28,OTHER, 18.55, 105.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37391,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 42.36,,CLAIM ADJUSTMENT 3, 154.63,OTHER, 42.36, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37392,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 204.30,OTHER, 138.19, 343.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37393,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 70.96,OTHER, 18.55, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37394,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 660.83,OTHER, 156.82, 1251.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37395,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 660.83,OTHER, 156.82, 1251.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37396,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 171.75,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37397,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 171.75,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37398,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 533.81,OTHER, 206.35, 972.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37399,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 533.81,OTHER, 206.35, 972.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37400,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 189.44,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37401,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 189.44,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37402,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 320.35,,CLAIM ADJUSTMENT 3, 757.92,OTHER, 320.35, 1367.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37403,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 320.35,,CLAIM ADJUSTMENT 3, 230.15,OTHER, 99.36, 320.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37404,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 322.62,,CLAIM ADJUSTMENT 3, 899.81,OTHER, 322.62, 1651.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37405,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 322.62,,CLAIM ADJUSTMENT 3, 230.96,OTHER, 99.36, 322.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37406,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 548.80,,CLAIM ADJUSTMENT 3, 1092.65,OTHER, 548.80, 1930.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37407,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 548.80,,CLAIM ADJUSTMENT 3, 311.74,OTHER, 99.36, 548.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37408,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 864.03,OTHER, 423.08, 1531.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37409,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 266.84,OTHER, 99.36, 423.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37410,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 344.89,OTHER, 215.00, 490.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37411,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 266.84,OTHER, 99.36, 423.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37412,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 830.31,OTHER, 410.92, 1470.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37413,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 262.50,OTHER, 99.36, 410.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37414,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 1103.77,OTHER, 410.92, 2018.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37415,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 262.50,OTHER, 99.36, 410.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37416,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 1111.16,OTHER, 359.95, 2058.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37417,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 244.29,OTHER, 99.36, 359.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37418,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 624.07,OTHER, 359.95, 1080.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37419,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 244.29,OTHER, 99.36, 359.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37420,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 672.34,OTHER, 360.01, 1177.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37421,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37422,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 559.38,OTHER, 360.01, 950.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37423,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37424,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 1228.06,OTHER, 360.01, 2292.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37425,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37426,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 1294.05,OTHER, 360.01, 2425.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37427,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37428,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37429,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37430,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 1149.19,OTHER, 775.51, 1767.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37431,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 1149.19,OTHER, 775.51, 1767.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37432,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 518.51,OTHER, 99.36, 1127.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37433,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 518.51,OTHER, 99.36, 1127.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37434,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 2267.81,OTHER, 1127.76, 4012.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37435,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 518.51,OTHER, 99.36, 1127.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37436,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 815.01,OTHER, 444.92, 1423.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37437,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 815.01,OTHER, 444.92, 1423.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37438,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 274.64,OTHER, 99.36, 444.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37439,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 274.64,OTHER, 99.36, 444.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37440,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.54,,CLAIM ADJUSTMENT 3, 635.79,OTHER, 283.54, 1140.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37441,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 283.54,,CLAIM ADJUSTMENT 3, 217.00,OTHER, 99.36, 283.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37442,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 300.36,,CLAIM ADJUSTMENT 3, 984.09,OTHER, 300.36, 1831.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37443,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 300.36,,CLAIM ADJUSTMENT 3, 223.01,OTHER, 99.36, 300.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37444,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 443.12,,CLAIM ADJUSTMENT 3, 1050.06,OTHER, 443.12, 1895.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37445,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 443.12,,CLAIM ADJUSTMENT 3, 274.00,OTHER, 99.36, 443.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37446,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 742.64,,CLAIM ADJUSTMENT 3, 684.67,OTHER, 447.20, 1019.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37447,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 742.64,,CLAIM ADJUSTMENT 3, 380.97,OTHER, 99.36, 742.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37448,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 2685.69,OTHER, 1509.32, 4668.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37449,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 744.80,OTHER, 176.64, 1509.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37450,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 2768.70,OTHER, 1509.32, 4835.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37451,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 744.80,OTHER, 176.64, 1509.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37452,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.78,,CLAIM ADJUSTMENT 3, 34.30,OTHER, 19.78, 59.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37453,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.18,,CLAIM ADJUSTMENT 3, 32.49,OTHER, 12.18, 59.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37454,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37455,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 10.09,,CLAIM ADJUSTMENT 3, 70.69,OTHER, 10.09, 137.05,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37456,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 15.20,,CLAIM ADJUSTMENT 3, 122.16,OTHER, 15.20, 237.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37457,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.28,,CLAIM ADJUSTMENT 3, 97.60,OTHER, 19.28, 186.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37458,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.28,,CLAIM ADJUSTMENT 3, 97.60,OTHER, 19.28, 186.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37459,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.50,,CLAIM ADJUSTMENT 3, 83.55,OTHER, 12.50, 161.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37460,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.50,,CLAIM ADJUSTMENT 3, 83.55,OTHER, 12.50, 161.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37461,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 68.59,,CLAIM ADJUSTMENT 3, 155.85,OTHER, 68.59, 280.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37462,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.76,,CLAIM ADJUSTMENT 3, 78.98,OTHER, 11.76, 152.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37463,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 22.37,,CLAIM ADJUSTMENT 3, 69.30,OTHER, 22.37, 128.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37464,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.28,,CLAIM ADJUSTMENT 3, 229.30,OTHER, 46.28, 438.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37465,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 88.95,OTHER, 20.98, 172.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37466,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 88.95,OTHER, 20.98, 172.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37467,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.13,,CLAIM ADJUSTMENT 3, 53.39,OTHER, 19.13, 98.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37468,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.13,,CLAIM ADJUSTMENT 3, 53.39,OTHER, 19.13, 98.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37469,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.50,,CLAIM ADJUSTMENT 3, 80.17,OTHER, 19.50, 151.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37470,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 31.20,,CLAIM ADJUSTMENT 3, 54.61,OTHER, 31.20, 94.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37471,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 80.03,OTHER, 19.08, 151.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37472,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 79.17,OTHER, 19.08, 149.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37473,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.52,,CLAIM ADJUSTMENT 3, 63.95,OTHER, 9.52, 123.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37474,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 22.37,,CLAIM ADJUSTMENT 3, 28.28,OTHER, 20.21, 46.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37475,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 83.69,OTHER, 19.08, 158.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37476,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 22.03,,CLAIM ADJUSTMENT 3, 53.47,OTHER, 22.03, 96.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37477,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 79.81,OTHER, 19.08, 151.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37478,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.78,,CLAIM ADJUSTMENT 3, 44.64,OTHER, 19.78, 80.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37479,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.78,,CLAIM ADJUSTMENT 3, 145.91,OTHER, 19.78, 283.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37480,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.36,,CLAIM ADJUSTMENT 3, 64.76,OTHER, 20.36, 120.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37481,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.16,,CLAIM ADJUSTMENT 3, 121.34,OTHER, 17.16, 235.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37482,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.50,,CLAIM ADJUSTMENT 3, 84.76,OTHER, 19.50, 160.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37483,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 32.53,,CLAIM ADJUSTMENT 3, 134.69,OTHER, 32.53, 254.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37484,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.84,,CLAIM ADJUSTMENT 3, 90.91,OTHER, 26.84, 169.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37485,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 56.90,OTHER, 10.75, 186.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37486,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 56.90,OTHER, 10.75, 186.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37487,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 23.85,OTHER, 17.20, 39.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37488,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 23.85,OTHER, 17.20, 39.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37489,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37490,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37491,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37492,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37493,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37494,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37495,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37496,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37497,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37498,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37499,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37500,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37501,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37502,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37503,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37504,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37505,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37506,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37507,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37508,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.56,,CLAIM ADJUSTMENT 3, 34.88,OTHER, 4.56, 67.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37509,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.56,,CLAIM ADJUSTMENT 3, 34.88,OTHER, 4.56, 67.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37510,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.56,,CLAIM ADJUSTMENT 3, 34.88,OTHER, 4.56, 67.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37511,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 20.93,OTHER, 3.24, 40.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37512,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 20.93,OTHER, 3.24, 40.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37513,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 20.93,OTHER, 3.24, 40.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37514,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 7.12,OTHER, 3.24, 12.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37515,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.12,,CLAIM ADJUSTMENT 3, 8.07,OTHER, 3.12, 14.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37516,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 33.86,OTHER, 12.40, 62.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37517,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 33.86,OTHER, 12.40, 62.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37518,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 75.71,OTHER, 12.40, 146.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37519,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 75.71,OTHER, 12.40, 146.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37520,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.66,,CLAIM ADJUSTMENT 3, 145.60,OTHER, 105.66, 241.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37521,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.66,,CLAIM ADJUSTMENT 3, 145.60,OTHER, 105.66, 241.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37522,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 94.12,,CLAIM ADJUSTMENT 3, 262.66,OTHER, 94.12, 482.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37523,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 131.99,,CLAIM ADJUSTMENT 3, 428.98,OTHER, 131.99, 797.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37524,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37525,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37526,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 37527,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.50,,CLAIM ADJUSTMENT 3, 53.15,OTHER, 6.50, 103.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37528,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.76,,CLAIM ADJUSTMENT 3, 38.90,OTHER, 11.76, 72.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37529,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 55.61,,CLAIM ADJUSTMENT 3, 146.83,OTHER, 55.61, 268.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37530,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.13,,CLAIM ADJUSTMENT 3, 20.13,OTHER, 7.13, 37.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37531,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.13,,CLAIM ADJUSTMENT 3, 20.13,OTHER, 7.13, 37.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37532,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.21,,CLAIM ADJUSTMENT 3, 28.92,OTHER, 11.21, 52.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37533,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.21,,CLAIM ADJUSTMENT 3, 28.92,OTHER, 11.21, 52.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37534,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.33,,CLAIM ADJUSTMENT 3, 60.58,OTHER, 8.33, 117.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37535,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.33,,CLAIM ADJUSTMENT 3, 60.58,OTHER, 8.33, 117.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37536,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 50.88,OTHER, 13.98, 95.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37537,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.36,,CLAIM ADJUSTMENT 3, 71.06,OTHER, 19.36, 133.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37538,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.82,,CLAIM ADJUSTMENT 3, 109.86,OTHER, 20.82, 210.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37539,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.14,,CLAIM ADJUSTMENT 3, 80.16,OTHER, 24.14, 149.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37540,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.14,,CLAIM ADJUSTMENT 3, 80.16,OTHER, 24.14, 149.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37541,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 63.10,OTHER, 20.98, 116.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37542,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 63.10,OTHER, 20.98, 116.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37543,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.34,,CLAIM ADJUSTMENT 3, 50.79,OTHER, 9.34, 97.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37544,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.34,,CLAIM ADJUSTMENT 3, 50.79,OTHER, 9.34, 97.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37545,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 42.16,,CLAIM ADJUSTMENT 3, 100.38,OTHER, 42.16, 181.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37546,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.34,,CLAIM ADJUSTMENT 3, 121.92,OTHER, 46.34, 222.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37547,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.37,,CLAIM ADJUSTMENT 3, 50.20,OTHER, 30.37, 86.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37548,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.31,,CLAIM ADJUSTMENT 3, 116.31,OTHER, 27.31, 220.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37549,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.24,,CLAIM ADJUSTMENT 3, 49.78,OTHER, 14.24, 93.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37550,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.30,,CLAIM ADJUSTMENT 3, 63.44,OTHER, 23.30, 116.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37551,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.22,,CLAIM ADJUSTMENT 3, 36.36,OTHER, 7.22, 69.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37552,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.22,,CLAIM ADJUSTMENT 3, 36.36,OTHER, 7.22, 69.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37553,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.22,,CLAIM ADJUSTMENT 3, 33.07,OTHER, 7.22, 62.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37554,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.31,,CLAIM ADJUSTMENT 3, 19.33,OTHER, 6.31, 35.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37555,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.38,,CLAIM ADJUSTMENT 3, 33.34,OTHER, 6.38, 63.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37556,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 22.92,,CLAIM ADJUSTMENT 3, 56.73,OTHER, 22.92, 102.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37557,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 42.62,,CLAIM ADJUSTMENT 3, 126.67,OTHER, 42.62, 244.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37558,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 42.62,,CLAIM ADJUSTMENT 3, 126.67,OTHER, 42.62, 244.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37559,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 42.62,,CLAIM ADJUSTMENT 3, 126.67,OTHER, 42.62, 244.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37560,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 38.58,,CLAIM ADJUSTMENT 3, 123.66,OTHER, 38.58, 229.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37561,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.43,,CLAIM ADJUSTMENT 3, 34.08,OTHER, 7.43, 64.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37562,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.43,,CLAIM ADJUSTMENT 3, 34.08,OTHER, 7.43, 64.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37563,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.43,,CLAIM ADJUSTMENT 3, 34.08,OTHER, 7.43, 64.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37564,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.70,,CLAIM ADJUSTMENT 3, 69.24,OTHER, 19.70, 129.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37565,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.69,,CLAIM ADJUSTMENT 3, 49.97,OTHER, 8.69, 96.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37566,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.58,,CLAIM ADJUSTMENT 3, 44.47,OTHER, 18.58, 80.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37567,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.74,,CLAIM ADJUSTMENT 3, 65.14,OTHER, 17.74, 122.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37568,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.30,,CLAIM ADJUSTMENT 3, 87.25,OTHER, 27.30, 162.05,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37569,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.30,,CLAIM ADJUSTMENT 3, 87.25,OTHER, 27.30, 162.05,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37570,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.29,,CLAIM ADJUSTMENT 3, 59.01,OTHER, 24.29, 106.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37571,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 36.36,,CLAIM ADJUSTMENT 3, 127.93,OTHER, 36.36, 240.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37572,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 36.36,,CLAIM ADJUSTMENT 3, 127.93,OTHER, 36.36, 240.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37573,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 56.46,OTHER, 15.47, 105.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37574,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.28,,CLAIM ADJUSTMENT 3, 13.69,OTHER, 8.28, 23.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37575,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.87,,CLAIM ADJUSTMENT 3, 73.71,OTHER, 17.87, 139.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37576,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.06,,CLAIM ADJUSTMENT 3, 87.73,OTHER, 24.06, 164.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37577,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.06,,CLAIM ADJUSTMENT 3, 87.73,OTHER, 24.06, 164.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37578,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.47,,CLAIM ADJUSTMENT 3, 66.31,OTHER, 23.47, 121.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37579,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.47,,CLAIM ADJUSTMENT 3, 66.31,OTHER, 23.47, 121.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37580,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 34.69,,CLAIM ADJUSTMENT 3, 190.19,OTHER, 34.69, 365.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37581,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 34.69,,CLAIM ADJUSTMENT 3, 214.01,OTHER, 34.69, 412.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37582,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.37,,CLAIM ADJUSTMENT 3, 47.49,OTHER, 9.37, 90.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37583,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.37,,CLAIM ADJUSTMENT 3, 47.49,OTHER, 9.37, 90.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37584,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.28,,CLAIM ADJUSTMENT 3, 41.70,OTHER, 19.28, 74.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37585,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.63,,CLAIM ADJUSTMENT 3, 59.73,OTHER, 16.63, 111.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37586,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.37,,CLAIM ADJUSTMENT 3, 31.62,OTHER, 7.37, 59.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37587,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.37,,CLAIM ADJUSTMENT 3, 31.62,OTHER, 7.37, 59.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37588,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.37,,CLAIM ADJUSTMENT 3, 31.62,OTHER, 7.37, 59.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37589,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 39.11,OTHER, 7.46, 74.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37590,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 39.11,OTHER, 7.46, 74.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37591,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.62,,CLAIM ADJUSTMENT 3, 93.47,OTHER, 13.62, 181.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37592,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.62,,CLAIM ADJUSTMENT 3, 93.47,OTHER, 13.62, 181.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37593,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.97,,CLAIM ADJUSTMENT 3, 45.06,OTHER, 16.97, 82.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37594,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 76.21,OTHER, 9.31, 148.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37595,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.72,,CLAIM ADJUSTMENT 3, 72.23,OTHER, 21.72, 134.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37596,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.72,,CLAIM ADJUSTMENT 3, 72.23,OTHER, 21.72, 134.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37597,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 75.36,OTHER, 26.66, 138.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37598,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 75.36,OTHER, 26.66, 138.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37599,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 36.38,,CLAIM ADJUSTMENT 3, 127.42,OTHER, 36.38, 238.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37600,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 36.38,,CLAIM ADJUSTMENT 3, 127.42,OTHER, 36.38, 238.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37601,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.06,,CLAIM ADJUSTMENT 3, 93.87,OTHER, 27.06, 175.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37602,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 40.24,,CLAIM ADJUSTMENT 3, 135.49,OTHER, 40.24, 252.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37603,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 40.24,,CLAIM ADJUSTMENT 3, 135.49,OTHER, 40.24, 252.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37604,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.51,,CLAIM ADJUSTMENT 3, 83.83,OTHER, 46.51, 146.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37605,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 34.82,,CLAIM ADJUSTMENT 3, 73.72,OTHER, 34.82, 131.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37606,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 35.93,,CLAIM ADJUSTMENT 3, 75.45,OTHER, 35.93, 134.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37607,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 33.53,,CLAIM ADJUSTMENT 3, 121.64,OTHER, 33.53, 228.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37608,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.34,,CLAIM ADJUSTMENT 3, 69.17,OTHER, 7.34, 135.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37609,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.19,,CLAIM ADJUSTMENT 3, 124.67,OTHER, 24.19, 238.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37610,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.63,,CLAIM ADJUSTMENT 3, 76.46,OTHER, 19.63, 144.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37611,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.17,,CLAIM ADJUSTMENT 3, 71.48,OTHER, 21.17, 133.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37612,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37613,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37614,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37615,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37616,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37617,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.70,,CLAIM ADJUSTMENT 3, 64.96,OTHER, 23.70, 119.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37618,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.54,,CLAIM ADJUSTMENT 3, 34.98,OTHER, 11.54, 64.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37619,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.54,,CLAIM ADJUSTMENT 3, 203.52,OTHER, 37.54, 390.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37620,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.39,,CLAIM ADJUSTMENT 3, 61.71,OTHER, 25.39, 111.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37621,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 25.64,OTHER, 5.66, 48.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37622,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 25.64,OTHER, 5.66, 48.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37623,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 25.64,OTHER, 5.66, 48.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37624,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 28.32,OTHER, 5.66, 54.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37625,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 28.32,OTHER, 5.66, 54.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37626,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 28.32,OTHER, 5.66, 54.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37627,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 14.14,OTHER, 5.66, 25.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37628,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 64.46,OTHER, 6.84, 126.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37629,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 64.46,OTHER, 6.84, 126.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37630,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.97,,CLAIM ADJUSTMENT 3, 57.91,OTHER, 13.97, 109.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37631,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 10.37,,CLAIM ADJUSTMENT 3, 37.55,OTHER, 10.37, 70.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37632,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.76,,CLAIM ADJUSTMENT 3, 94.73,OTHER, 26.76, 177.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37633,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.76,,CLAIM ADJUSTMENT 3, 94.73,OTHER, 26.76, 177.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37634,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 94.52,OTHER, 26.66, 176.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37635,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 94.52,OTHER, 26.66, 176.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37636,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.12,,CLAIM ADJUSTMENT 3, 67.05,OTHER, 18.12, 125.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37637,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 31.62,,CLAIM ADJUSTMENT 3, 74.92,OTHER, 31.62, 135.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37638,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 48.30,OTHER, 13.98, 90.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37639,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 48.30,OTHER, 13.98, 90.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37640,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 48.30,OTHER, 13.98, 90.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37641,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.80,,CLAIM ADJUSTMENT 3, 99.83,OTHER, 25.80, 188.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37642,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37643,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37644,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37645,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37646,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37647,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37648,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.86,,CLAIM ADJUSTMENT 3, 128.28,OTHER, 24.86, 290.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37649,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.86,,CLAIM ADJUSTMENT 3, 128.28,OTHER, 24.86, 290.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37650,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.86,,CLAIM ADJUSTMENT 3, 128.28,OTHER, 24.86, 290.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37651,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 25.93,OTHER, 18.49, 42.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37652,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.46,,CLAIM ADJUSTMENT 3, 69.04,OTHER, 16.46, 130.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37653,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 43.88,OTHER, 9.31, 83.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37654,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 43.88,OTHER, 9.31, 83.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37655,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 43.88,OTHER, 9.31, 83.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37656,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37657,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37658,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37659,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37660,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.66,,CLAIM ADJUSTMENT 3, 70.04,OTHER, 16.66, 132.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37661,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.70,,CLAIM ADJUSTMENT 3, 51.00,OTHER, 8.70, 111.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37662,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.70,,CLAIM ADJUSTMENT 3, 51.00,OTHER, 8.70, 111.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37663,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.42,,CLAIM ADJUSTMENT 3, 85.45,OTHER, 18.42, 162.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37664,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 28.37,,CLAIM ADJUSTMENT 3, 68.77,OTHER, 28.37, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37665,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.44,,CLAIM ADJUSTMENT 3, 54.77,OTHER, 17.44, 101.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37666,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.44,,CLAIM ADJUSTMENT 3, 54.77,OTHER, 17.44, 101.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37667,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.92,,CLAIM ADJUSTMENT 3, 60.48,OTHER, 9.92, 116.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37668,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.92,,CLAIM ADJUSTMENT 3, 60.48,OTHER, 9.92, 116.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37669,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 66.68,,CLAIM ADJUSTMENT 3, 149.05,OTHER, 66.68, 267.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37670,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 49.24,,CLAIM ADJUSTMENT 3, 43.46,OTHER, 27.95, 63.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37671,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 15.12,,CLAIM ADJUSTMENT 3, 43.01,OTHER, 15.12, 79.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37672,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 15.12,,CLAIM ADJUSTMENT 3, 43.01,OTHER, 15.12, 79.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37673,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.65,,CLAIM ADJUSTMENT 3, 40.64,OTHER, 9.65, 76.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37674,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 34.72,,CLAIM ADJUSTMENT 3, 204.04,OTHER, 34.72, 392.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37675,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.41,,CLAIM ADJUSTMENT 3, 57.49,OTHER, 23.41, 104.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37676,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 159.56,OTHER, 24.40, 308.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37677,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 159.56,OTHER, 24.40, 308.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37678,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.60,,CLAIM ADJUSTMENT 3, 74.79,OTHER, 18.60, 163.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37679,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.60,,CLAIM ADJUSTMENT 3, 74.79,OTHER, 18.60, 163.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37680,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 56.53,,CLAIM ADJUSTMENT 3, 120.40,OTHER, 56.53, 214.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37681,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 56.53,,CLAIM ADJUSTMENT 3, 120.40,OTHER, 56.53, 214.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37682,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.54,,CLAIM ADJUSTMENT 3, 110.95,OTHER, 30.54, 208.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37683,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.52,,CLAIM ADJUSTMENT 3, 54.17,OTHER, 9.52, 104.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37684,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.82,,CLAIM ADJUSTMENT 3, 44.45,OTHER, 9.82, 84.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37685,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.82,,CLAIM ADJUSTMENT 3, 44.45,OTHER, 9.82, 84.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37686,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.81,,CLAIM ADJUSTMENT 3, 86.15,OTHER, 20.81, 162.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37687,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 59.45,,CLAIM ADJUSTMENT 3, 147.00,OTHER, 59.45, 266.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37688,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 59.45,,CLAIM ADJUSTMENT 3, 147.00,OTHER, 59.45, 266.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37689,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.89,,CLAIM ADJUSTMENT 3, 43.75,OTHER, 27.89, 74.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37690,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 28.27,,CLAIM ADJUSTMENT 3, 186.61,OTHER, 28.27, 361.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37691,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 45.87,OTHER, 7.46, 92.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37692,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 45.87,OTHER, 7.46, 92.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37693,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.83,,CLAIM ADJUSTMENT 3, 35.19,OTHER, 6.83, 67.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37694,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.83,,CLAIM ADJUSTMENT 3, 35.19,OTHER, 6.83, 67.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37695,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.85,,CLAIM ADJUSTMENT 3, 28.87,OTHER, 6.85, 54.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37696,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.82,,CLAIM ADJUSTMENT 3, 13.83,OTHER, 6.82, 24.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37697,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.01,,CLAIM ADJUSTMENT 3, 45.56,OTHER, 21.01, 81.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37698,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.04,,CLAIM ADJUSTMENT 3, 92.72,OTHER, 30.04, 171.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37699,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.04,,CLAIM ADJUSTMENT 3, 92.72,OTHER, 30.04, 171.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37700,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 39.19,,CLAIM ADJUSTMENT 3, 102.79,OTHER, 39.19, 187.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37701,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.91,,CLAIM ADJUSTMENT 3, 97.17,OTHER, 27.91, 181.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37702,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.48,,CLAIM ADJUSTMENT 3, 90.21,OTHER, 26.48, 174.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37703,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.48,,CLAIM ADJUSTMENT 3, 90.21,OTHER, 26.48, 174.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37704,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.48,,CLAIM ADJUSTMENT 3, 93.39,OTHER, 26.48, 174.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37705,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 24.66,OTHER, 5.28, 46.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37706,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 24.66,OTHER, 5.28, 46.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37707,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 57.84,OTHER, 5.28, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37708,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 57.84,OTHER, 5.28, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37709,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 57.84,OTHER, 5.28, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37710,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.76,,CLAIM ADJUSTMENT 3, 41.90,OTHER, 5.76, 83.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37711,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.76,,CLAIM ADJUSTMENT 3, 41.90,OTHER, 5.76, 83.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37712,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.76,,CLAIM ADJUSTMENT 3, 41.90,OTHER, 5.76, 83.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37713,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 144.06,OTHER, 15.47, 390.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37714,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 144.06,OTHER, 15.47, 390.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37715,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.68,,CLAIM ADJUSTMENT 3, 141.59,OTHER, 25.68, 394.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37716,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.68,,CLAIM ADJUSTMENT 3, 141.59,OTHER, 25.68, 394.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37717,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 38.44,,CLAIM ADJUSTMENT 3, 136.35,OTHER, 38.44, 255.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37718,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 40.46,,CLAIM ADJUSTMENT 3, 103.27,OTHER, 40.46, 187.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37719,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 31.67,,CLAIM ADJUSTMENT 3, 76.88,OTHER, 31.67, 139.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37720,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.15,,CLAIM ADJUSTMENT 3, 178.83,OTHER, 29.15, 344.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37721,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 31.30,,CLAIM ADJUSTMENT 3, 88.43,OTHER, 31.30, 162.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37722,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.92,,CLAIM ADJUSTMENT 3, 30.02,OTHER, 6.92, 56.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37723,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.92,,CLAIM ADJUSTMENT 3, 30.02,OTHER, 6.92, 56.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37724,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.28,,CLAIM ADJUSTMENT 3, 34.17,OTHER, 7.28, 88.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37725,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.28,,CLAIM ADJUSTMENT 3, 34.17,OTHER, 7.28, 88.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37726,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.28,,CLAIM ADJUSTMENT 3, 34.17,OTHER, 7.28, 88.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37727,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.61,,CLAIM ADJUSTMENT 3, 180.72,OTHER, 30.61, 348.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37728,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.66,,CLAIM ADJUSTMENT 3, 302.95,OTHER, 11.66, 602.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37729,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 36.67,,CLAIM ADJUSTMENT 3, 81.90,OTHER, 36.67, 146.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37730,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37731,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37732,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37733,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37734,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.58,,CLAIM ADJUSTMENT 3, 86.80,OTHER, 30.58, 159.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37735,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.58,,CLAIM ADJUSTMENT 3, 86.80,OTHER, 30.58, 159.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37736,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.12,,CLAIM ADJUSTMENT 3, 107.35,OTHER, 23.12, 204.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37737,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.12,,CLAIM ADJUSTMENT 3, 107.35,OTHER, 23.12, 204.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37738,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.89,,CLAIM ADJUSTMENT 3, 53.27,OTHER, 9.89, 102.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37739,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.89,,CLAIM ADJUSTMENT 3, 53.27,OTHER, 9.89, 102.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37740,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.98,,CLAIM ADJUSTMENT 3, 75.95,OTHER, 12.98, 146.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37741,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.98,,CLAIM ADJUSTMENT 3, 75.95,OTHER, 12.98, 146.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37742,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.98,,CLAIM ADJUSTMENT 3, 75.95,OTHER, 12.98, 146.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37743,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.29,,CLAIM ADJUSTMENT 3, 51.95,OTHER, 21.29, 94.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37744,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.19,,CLAIM ADJUSTMENT 3, 73.53,OTHER, 24.19, 136.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37745,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 73.24,,CLAIM ADJUSTMENT 3, 154.17,OTHER, 73.24, 274.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37746,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 73.24,,CLAIM ADJUSTMENT 3, 154.17,OTHER, 73.24, 274.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37747,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.42,,CLAIM ADJUSTMENT 3, 49.79,OTHER, 20.42, 90.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37748,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 38.32,OTHER, 7.46, 73.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37749,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.63,,CLAIM ADJUSTMENT 3, 35.99,OTHER, 7.63, 68.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37750,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.37,,CLAIM ADJUSTMENT 3, 58.51,OTHER, 18.37, 108.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37751,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.27,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 8.27, 74.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37752,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.42,,CLAIM ADJUSTMENT 3, 79.41,OTHER, 20.42, 149.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37753,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.42,,CLAIM ADJUSTMENT 3, 79.41,OTHER, 20.42, 149.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37754,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 78.90,OTHER, 24.40, 146.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37755,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 78.90,OTHER, 24.40, 146.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37756,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 22.69,,CLAIM ADJUSTMENT 3, 126.89,OTHER, 22.69, 243.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37757,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.95,,CLAIM ADJUSTMENT 3, 82.99,OTHER, 17.95, 157.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37758,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.95,,CLAIM ADJUSTMENT 3, 82.99,OTHER, 17.95, 157.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37759,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.69,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 5.69, 75.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37760,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.69,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 5.69, 75.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37761,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.69,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 5.69, 75.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37762,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.00,,CLAIM ADJUSTMENT 3, 22.60,OTHER, 8.00, 41.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37763,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.00,,CLAIM ADJUSTMENT 3, 22.60,OTHER, 8.00, 41.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37764,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.50,,CLAIM ADJUSTMENT 3, 31.87,OTHER, 6.50, 60.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37765,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.32,,CLAIM ADJUSTMENT 3, 39.10,OTHER, 7.32, 74.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37766,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.72,,CLAIM ADJUSTMENT 3, 76.33,OTHER, 16.72, 145.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37767,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.75,,CLAIM ADJUSTMENT 3, 103.71,OTHER, 19.75, 198.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37768,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.40,,CLAIM ADJUSTMENT 3, 56.68,OTHER, 16.40, 105.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37769,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.40,,CLAIM ADJUSTMENT 3, 56.68,OTHER, 16.40, 105.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37770,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.40,,CLAIM ADJUSTMENT 3, 56.68,OTHER, 16.40, 105.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37771,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 29.96, 157.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37772,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.67,,CLAIM ADJUSTMENT 3, 97.04,OTHER, 21.67, 184.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37773,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.94,,CLAIM ADJUSTMENT 3, 42.88,OTHER, 6.94, 82.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37774,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.47,,CLAIM ADJUSTMENT 3, 43.80,OTHER, 5.47, 85.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37775,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 17.85,OTHER, 3.41, 34.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37776,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 17.85,OTHER, 3.41, 34.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37777,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 21.46,OTHER, 3.41, 41.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37778,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 21.46,OTHER, 3.41, 41.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37779,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 22.31,OTHER, .01, 84.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37780,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.18,,CLAIM ADJUSTMENT 3, 22.31,OTHER, .01, 84.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37781,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 44.71,OTHER, 9.31, 85.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37782,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.75,,CLAIM ADJUSTMENT 3, 37.65,OTHER, 5.75, 72.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37783,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.75,,CLAIM ADJUSTMENT 3, 37.65,OTHER, 5.75, 72.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37784,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.66,,CLAIM ADJUSTMENT 3, 19.92,OTHER, 3.66, 38.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37785,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.46,,CLAIM ADJUSTMENT 3, 32.63,OTHER, 6.46, 62.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37786,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.78,,CLAIM ADJUSTMENT 3, 96.77,OTHER, 25.78, 181.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37787,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 33.04,,CLAIM ADJUSTMENT 3, 129.31,OTHER, 33.04, 243.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37788,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.06,,CLAIM ADJUSTMENT 3, 130.54,OTHER, 17.06, 253.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37789,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.93,,CLAIM ADJUSTMENT 3, 98.34,OTHER, 19.93, 187.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37790,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 22.06,,CLAIM ADJUSTMENT 3, 89.00,OTHER, 22.06, 168.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37791,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.66,,CLAIM ADJUSTMENT 3, 98.22,OTHER, 14.66, 190.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37792,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.99,,CLAIM ADJUSTMENT 3, 54.63,OTHER, 13.99, 102.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37793,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.00,,CLAIM ADJUSTMENT 3, 70.40,OTHER, 27.00, 128.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37794,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 29.86,OTHER, 6.18, 57.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37795,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 29.86,OTHER, 6.18, 57.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37796,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 29.86,OTHER, 6.18, 57.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37797,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37798,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37799,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37800,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37801,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 41.60,OTHER, 6.14, 80.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37802,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 3.89,,CLAIM ADJUSTMENT 3, 26.32,OTHER, 3.89, 50.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37803,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.93,,CLAIM ADJUSTMENT 3, 36.35,OTHER, 7.93, 69.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37804,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.65,,CLAIM ADJUSTMENT 3, 61.85,OTHER, 8.65, 166.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37805,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.65,,CLAIM ADJUSTMENT 3, 61.85,OTHER, 8.65, 166.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37806,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.26,,CLAIM ADJUSTMENT 3, 76.67,OTHER, 11.26, 148.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37807,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37808,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37809,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37810,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37811,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37812,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37813,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37814,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37815,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37816,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37817,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37818,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37819,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37820,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37821,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37822,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37823,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37824,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37825,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37826,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37827,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37828,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37829,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37830,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37831,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37832,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37833,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37834,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37835,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37836,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37837,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37838,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37839,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37840,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37841,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37842,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37843,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37844,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37845,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37846,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37847,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37848,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37849,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37850,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37851,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37852,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37853,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37854,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37855,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37856,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37857,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37858,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37859,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37860,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37861,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37862,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37863,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37864,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37865,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37866,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37867,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37868,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37869,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.45,,CLAIM ADJUSTMENT 3, 189.29,OTHER, 26.45, 367.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37870,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.46,,CLAIM ADJUSTMENT 3, 115.17,OTHER, 14.46, 224.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37871,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.41,,CLAIM ADJUSTMENT 3, 91.70,OTHER, 17.41, 220.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37872,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.41,,CLAIM ADJUSTMENT 3, 91.70,OTHER, 17.41, 220.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37873,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.07,,CLAIM ADJUSTMENT 3, 48.91,OTHER, 16.07, 90.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37874,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 10.51,,CLAIM ADJUSTMENT 3, 45.23,OTHER, 10.51, 85.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37875,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 17.08,OTHER, 7.46, 30.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37876,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 17.08,OTHER, 7.46, 30.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37877,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.65,,CLAIM ADJUSTMENT 3, 59.25,OTHER, 18.65, 110.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37878,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 36.65,,CLAIM ADJUSTMENT 3, 93.98,OTHER, 36.65, 171.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37879,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 36.65,,CLAIM ADJUSTMENT 3, 137.37,OTHER, 36.65, 258.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37880,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.14,,CLAIM ADJUSTMENT 3, 78.46,OTHER, 23.14, 146.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37881,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.28,,CLAIM ADJUSTMENT 3, 67.64,OTHER, 17.28, 127.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37882,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.28,,CLAIM ADJUSTMENT 3, 67.64,OTHER, 17.28, 127.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37883,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.26,,CLAIM ADJUSTMENT 3, 77.69,OTHER, 29.26, 141.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37884,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.65,,CLAIM ADJUSTMENT 3, 63.19,OTHER, 18.65, 117.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37885,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.79,,CLAIM ADJUSTMENT 3, 65.88,OTHER, 19.79, 127.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37886,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.79,,CLAIM ADJUSTMENT 3, 65.88,OTHER, 19.79, 127.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37887,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37888,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37889,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37890,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37891,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37892,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37893,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 68.02,OTHER, 17.35, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37894,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 68.02,OTHER, 17.35, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37895,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 68.02,OTHER, 17.35, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37896,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 120.82,OTHER, 17.35, 238.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37897,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 120.82,OTHER, 17.35, 238.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37898,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.46,,CLAIM ADJUSTMENT 3, 15.65,OTHER, 10.75, 24.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37899,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 80.94,OTHER, 29.96, 150.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37900,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 80.94,OTHER, 29.96, 150.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37901,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 85.12,OTHER, 29.96, 156.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37902,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 103.45,OTHER, 29.96, 193.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37903,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.97,,CLAIM ADJUSTMENT 3, 125.05,OTHER, 24.97, 345.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37904,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.97,,CLAIM ADJUSTMENT 3, 125.05,OTHER, 24.97, 345.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37905,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 50.54,OTHER, 7.46, 97.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37906,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 32.17,,CLAIM ADJUSTMENT 3, 88.87,OTHER, 32.17, 162.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37907,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.83,,CLAIM ADJUSTMENT 3, 66.43,OTHER, 30.83, 118.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37908,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.72,,CLAIM ADJUSTMENT 3, 57.43,OTHER, 21.72, 104.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37909,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 33.95,,CLAIM ADJUSTMENT 3, 265.06,OTHER, 33.95, 515.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37910,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 80.97,OTHER, 38.57, 144.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37911,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 80.97,OTHER, 38.57, 144.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37912,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 54.34,,CLAIM ADJUSTMENT 3, 111.82,OTHER, 54.34, 198.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37913,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 67.64,,CLAIM ADJUSTMENT 3, 176.22,OTHER, 67.64, 321.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37914,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 88.05,OTHER, 38.57, 158.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37915,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 88.05,OTHER, 38.57, 158.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37916,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.84,,CLAIM ADJUSTMENT 3, 68.73,OTHER, 13.84, 131.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37917,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.95,,CLAIM ADJUSTMENT 3, 96.09,OTHER, 20.95, 205.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37918,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.95,,CLAIM ADJUSTMENT 3, 96.09,OTHER, 20.95, 205.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37919,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.60,,CLAIM ADJUSTMENT 3, 70.10,OTHER, 19.60, 131.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37920,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.16,,CLAIM ADJUSTMENT 3, 46.86,OTHER, 8.16, 90.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37921,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.16,,CLAIM ADJUSTMENT 3, 46.86,OTHER, 8.16, 90.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37922,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 89.24,,CLAIM ADJUSTMENT 3, 191.67,OTHER, 89.24, 342.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37923,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.33,,CLAIM ADJUSTMENT 3, 12.31,OTHER, 8.04, 18.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37924,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.34,,CLAIM ADJUSTMENT 3, 18.56,OTHER, 6.34, 34.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37925,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.67,,CLAIM ADJUSTMENT 3, 36.21,OTHER, 21.67, 62.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37926,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.66,,CLAIM ADJUSTMENT 3, 55.25,OTHER, 14.66, 103.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37927,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.58,,CLAIM ADJUSTMENT 3, 40.13,OTHER, 18.58, 71.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37928,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.00,,CLAIM ADJUSTMENT 3, 66.54,OTHER, 19.00, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37929,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.53,,CLAIM ADJUSTMENT 3, 88.38,OTHER, 24.53, 165.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37930,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.53,,CLAIM ADJUSTMENT 3, 88.38,OTHER, 24.53, 165.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37931,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.53,,CLAIM ADJUSTMENT 3, 88.38,OTHER, 24.53, 165.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37932,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.29,,CLAIM ADJUSTMENT 3, 26.75,OTHER, 17.29, 45.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37933,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.51,,CLAIM ADJUSTMENT 3, 91.08,OTHER, 16.51, 254.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37934,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.51,,CLAIM ADJUSTMENT 3, 91.08,OTHER, 16.51, 254.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37935,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 50.83,OTHER, 20.72, 92.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37936,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 59.00,OTHER, 24.26, 106.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37937,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 22.02,,CLAIM ADJUSTMENT 3, 64.46,OTHER, 22.02, 118.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37938,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.12,,CLAIM ADJUSTMENT 3, 59.50,OTHER, 26.12, 106.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37939,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 26.12,,CLAIM ADJUSTMENT 3, 59.50,OTHER, 26.12, 106.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37940,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 71.41,OTHER, 24.26, 179.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37941,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 71.41,OTHER, 24.26, 179.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37942,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 71.41,OTHER, 24.26, 179.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37943,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.86,,CLAIM ADJUSTMENT 3, 66.70,OTHER, 27.86, 120.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37944,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.86,,CLAIM ADJUSTMENT 3, 66.70,OTHER, 27.86, 120.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37945,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 43.51,OTHER, 20.72, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37946,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.00,,CLAIM ADJUSTMENT 3, 47.68,OTHER, 19.00, 86.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37947,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 27.86,,CLAIM ADJUSTMENT 3, 58.39,OTHER, 27.86, 103.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37948,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.86,,CLAIM ADJUSTMENT 3, 77.47,OTHER, 19.86, 145.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37949,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.74,,CLAIM ADJUSTMENT 3, 62.50,OTHER, 19.74, 116.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37950,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 46.75,OTHER, 17.35, 85.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37951,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.94,,CLAIM ADJUSTMENT 3, 41.14,OTHER, 16.94, 74.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37952,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 67.08,OTHER, 15.47, 127.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37953,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.84,,CLAIM ADJUSTMENT 3, 50.52,OTHER, 17.84, 92.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37954,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.21,,CLAIM ADJUSTMENT 3, 28.18,OTHER, 16.21, 48.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37955,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.79,,CLAIM ADJUSTMENT 3, 52.54,OTHER, 18.79, 96.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37956,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.79,,CLAIM ADJUSTMENT 3, 52.54,OTHER, 18.79, 96.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37957,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.07,,CLAIM ADJUSTMENT 3, 41.16,OTHER, 19.07, 73.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37958,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 46.11,OTHER, 20.72, 82.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37959,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 46.11,OTHER, 20.72, 82.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37960,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 46.11,OTHER, 20.72, 82.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37961,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 48.00,OTHER, 18.55, 88.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37962,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 48.00,OTHER, 18.55, 88.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37963,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 48.00,OTHER, 18.55, 88.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37964,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.07,,CLAIM ADJUSTMENT 3, 49.38,OTHER, 19.07, 89.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37965,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 80.11,OTHER, 18.55, 151.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37966,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 80.11,OTHER, 18.55, 151.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37967,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 361.76,OTHER, 18.55, 717.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37968,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 20.54,,CLAIM ADJUSTMENT 3, 161.64,OTHER, 20.54, 314.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37969,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 92.44,,CLAIM ADJUSTMENT 3, 158.63,OTHER, 92.44, 274.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37970,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 92.44,,CLAIM ADJUSTMENT 3, 158.63,OTHER, 92.44, 274.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37971,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.06,,CLAIM ADJUSTMENT 3, 78.01,OTHER, 14.06, 149.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37972,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.06,,CLAIM ADJUSTMENT 3, 78.01,OTHER, 14.06, 149.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37973,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.06,,CLAIM ADJUSTMENT 3, 78.01,OTHER, 14.06, 149.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37974,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 152.44,OTHER, 102.77, 234.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37975,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 251.30,,CLAIM ADJUSTMENT 3, 270.23,OTHER, 185.27, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37976,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 251.30,,CLAIM ADJUSTMENT 3, 270.23,OTHER, 185.27, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37977,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 251.30,,CLAIM ADJUSTMENT 3, 270.23,OTHER, 185.27, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37978,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37979,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37980,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37981,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37982,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37983,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 146.86,OTHER, 7.46, 291.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37984,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 54.74,OTHER, 4.31, 107.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37985,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 54.74,OTHER, 4.31, 107.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37986,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 54.74,OTHER, 4.31, 107.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37987,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 44.77,OTHER, 4.31, 89.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37988,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 44.77,OTHER, 4.31, 89.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37989,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 44.77,OTHER, 4.31, 89.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37990,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.52,,CLAIM ADJUSTMENT 3, 205.30,OTHER, 5.52, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37991,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.52,,CLAIM ADJUSTMENT 3, 205.30,OTHER, 5.52, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37992,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.52,,CLAIM ADJUSTMENT 3, 205.30,OTHER, 5.52, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37993,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.16,,CLAIM ADJUSTMENT 3, 70.78,OTHER, 11.16, 136.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37994,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.16,,CLAIM ADJUSTMENT 3, 70.78,OTHER, 11.16, 136.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37995,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37996,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37997,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37998,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 37999,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38000,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38001,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 35.20,,CLAIM ADJUSTMENT 3, 76.50,OTHER, 35.20, 136.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38002,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 91.25,,CLAIM ADJUSTMENT 3, 149.18,OTHER, 91.25, 255.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38003,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.86,,CLAIM ADJUSTMENT 3, 81.41,OTHER, 14.86, 156.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38004,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.86,,CLAIM ADJUSTMENT 3, 81.41,OTHER, 14.86, 156.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38005,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.60,,CLAIM ADJUSTMENT 3, 30.76,OTHER, 13.60, 55.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38006,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.41,,CLAIM ADJUSTMENT 3, 72.64,OTHER, 12.41, 139.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38007,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.41,,CLAIM ADJUSTMENT 3, 72.64,OTHER, 12.41, 139.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38008,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.63,,CLAIM ADJUSTMENT 3, 78.26,OTHER, 13.63, 150.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38009,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 13.63,,CLAIM ADJUSTMENT 3, 78.26,OTHER, 13.63, 150.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38010,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 78.99,OTHER, 11.64, 152.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38011,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 46.77,OTHER, 11.64, 88.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38012,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 46.77,OTHER, 11.64, 88.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38013,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 46.77,OTHER, 11.64, 88.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38014,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 9.55,,CLAIM ADJUSTMENT 3, 40.96,OTHER, 9.55, 77.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38015,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.62,,CLAIM ADJUSTMENT 3, 44.68,OTHER, 11.62, 84.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38016,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.62,,CLAIM ADJUSTMENT 3, 44.68,OTHER, 11.62, 84.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38017,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.62,,CLAIM ADJUSTMENT 3, 44.68,OTHER, 11.62, 84.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38018,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.65,,CLAIM ADJUSTMENT 3, 82.26,OTHER, 11.65, 159.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38019,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 11.65,,CLAIM ADJUSTMENT 3, 82.26,OTHER, 11.65, 159.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38020,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.11,,CLAIM ADJUSTMENT 3, 74.74,OTHER, 12.11, 144.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38021,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 15.55,,CLAIM ADJUSTMENT 3, 91.00,OTHER, 15.55, 175.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38022,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.82,,CLAIM ADJUSTMENT 3, 68.31,OTHER, 12.82, 130.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38023,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 17.74,OTHER, 6.84, 32.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38024,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 10.78,,CLAIM ADJUSTMENT 3, 22.99,OTHER, 10.78, 40.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38025,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 29.95,OTHER, 6.84, 56.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38026,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 12.46,,CLAIM ADJUSTMENT 3, 42.41,OTHER, 12.46, 79.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38027,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38028,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38029,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38030,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38031,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38032,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 38.14,OTHER, 7.76, 72.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38033,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 38.14,OTHER, 7.76, 72.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38034,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.38,,CLAIM ADJUSTMENT 3, 28.29,OTHER, 8.38, 52.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38035,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 28.16,,CLAIM ADJUSTMENT 3, 68.72,OTHER, 28.16, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38036,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.26,,CLAIM ADJUSTMENT 3, 299.39,OTHER, 17.26, 592.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38037,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 14.88,,CLAIM ADJUSTMENT 3, 40.67,OTHER, 14.88, 74.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38038,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 43.08,OTHER, 16.61, 78.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38039,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 121.25,OTHER, 19.08, 234.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38040,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 28.87,,CLAIM ADJUSTMENT 3, 68.89,OTHER, 28.87, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38041,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 106.28,OTHER, 50.53, 189.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38042,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 106.28,OTHER, 50.53, 189.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38043,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 53.66,,CLAIM ADJUSTMENT 3, 107.02,OTHER, 53.66, 189.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38044,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 53.66,,CLAIM ADJUSTMENT 3, 107.02,OTHER, 53.66, 189.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38045,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 53.66,,CLAIM ADJUSTMENT 3, 107.02,OTHER, 53.66, 189.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38046,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 198.86,OTHER, 61.69, 369.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38047,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 198.86,OTHER, 61.69, 369.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38048,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38049,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 221.47,OTHER, 61.69, 415.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38050,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 76.43,OTHER, 50.53, 129.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38051,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 122.54,,CLAIM ADJUSTMENT 3, 265.03,OTHER, 122.54, 473.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38052,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 106.28,OTHER, 50.53, 189.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38053,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38054,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38055,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 600.16,,CLAIM ADJUSTMENT 3, 445.68,OTHER, 266.63, 607.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38056,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38057,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38058,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38059,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 193.99,OTHER, 50.53, 365.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38060,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 193.99,OTHER, 50.53, 365.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38061,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38062,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 173.66,OTHER, 50.53, 324.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38063,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 28.87,,CLAIM ADJUSTMENT 3, 68.89,OTHER, 28.87, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38064,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 204.22,OTHER, 50.53, 599.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38065,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 204.22,OTHER, 50.53, 599.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38066,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 146.52,OTHER, 61.69, 264.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38067,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 146.52,OTHER, 61.69, 264.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38068,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.83,,CLAIM ADJUSTMENT 3, 62.25,OTHER, 23.83, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38069,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.83,,CLAIM ADJUSTMENT 3, 62.25,OTHER, 23.83, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38070,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.86,,CLAIM ADJUSTMENT 3, 43.07,OTHER, 18.86, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38071,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.86,,CLAIM ADJUSTMENT 3, 43.07,OTHER, 18.86, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38072,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.81,,CLAIM ADJUSTMENT 3, 44.25,OTHER, 23.81, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38073,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.81,,CLAIM ADJUSTMENT 3, 17.88,OTHER, 10.75, 24.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38074,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 23.14,,CLAIM ADJUSTMENT 3, 100.14,OTHER, 23.14, 189.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38075,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 370.73,,CLAIM ADJUSTMENT 3, 800.72,OTHER, 370.73, 1429.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38076,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 370.73,,CLAIM ADJUSTMENT 3, 800.72,OTHER, 370.73, 1429.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38077,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 38.32,,CLAIM ADJUSTMENT 3, 59.91,OTHER, 38.32, 101.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38078,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 38.32,,CLAIM ADJUSTMENT 3, 59.91,OTHER, 38.32, 101.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38079,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 97.97,,CLAIM ADJUSTMENT 3, 294.34,OTHER, 97.97, 543.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38080,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38081,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38082,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.79,,CLAIM ADJUSTMENT 3, 16.75,OTHER, 6.79, 30.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38083,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 6.79,,CLAIM ADJUSTMENT 3, 16.75,OTHER, 6.79, 30.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38084,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 8.06,,CLAIM ADJUSTMENT 3, 56.81,OTHER, 8.06, 110.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38085,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 10.56,,CLAIM ADJUSTMENT 3, 39.98,OTHER, 10.56, 75.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38086,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 41.73,OTHER, 17.35, 75.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38087,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38088,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 63.90,OTHER, 37.34, 110.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38089,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 63.90,OTHER, 37.34, 110.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38090,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 23.30,OTHER, 12.69, 37.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38091,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 37.95,OTHER, 25.59, 58.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38092,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 23.42,OTHER, 12.79, 37.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38093,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38094,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38095,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 315.54,,CLAIM ADJUSTMENT 3, 149.84,OTHER, 65.79, 315.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38096,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 315.54,,CLAIM ADJUSTMENT 3, 149.84,OTHER, 65.79, 315.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38097,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38098,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 71.34,,CLAIM ADJUSTMENT 3, 41.40,OTHER, 21.50, 71.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38099,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 71.34,,CLAIM ADJUSTMENT 3, 41.40,OTHER, 21.50, 71.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38100,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 280.30,,CLAIM ADJUSTMENT 3, 356.50,OTHER, 255.16, 581.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38101,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 345.38,,CLAIM ADJUSTMENT 3, 687.64,OTHER, 345.38, 1214.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38102,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38103,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38104,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38105,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 77.65,,CLAIM ADJUSTMENT 3, 60.00,OTHER, 36.55, 83.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38106,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 48.79,,CLAIM ADJUSTMENT 3, 36.74,OTHER, 22.12, 50.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38107,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 48.79,,CLAIM ADJUSTMENT 3, 36.74,OTHER, 22.12, 50.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38108,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38109,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38110,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38111,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38112,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38113,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38114,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38115,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38116,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38117,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38118,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38119,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.83,,CLAIM ADJUSTMENT 3, 111.30,OTHER, 67.85, 154.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38120,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.83,,CLAIM ADJUSTMENT 3, 111.30,OTHER, 67.85, 154.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38121,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38122,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38123,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 89.44,,CLAIM ADJUSTMENT 3, 104.75,OTHER, 73.49, 167.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38124,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 89.44,,CLAIM ADJUSTMENT 3, 104.75,OTHER, 73.49, 167.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38125,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 33.16,,CLAIM ADJUSTMENT 3, 12.78,OTHER, 4.30, 33.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38126,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 5.09,,CLAIM ADJUSTMENT 3, 17.36,OTHER, 5.09, 32.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38127,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 184.48,OTHER, 130.68, 297.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38128,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 202.35,OTHER, 146.42, 333.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38129,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 113.95,,CLAIM ADJUSTMENT 3, 99.37,OTHER, 63.61, 144.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38130,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 59.56,,CLAIM ADJUSTMENT 3, 88.44,OTHER, 59.56, 149.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38131,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 131.72,OTHER, 84.22, 191.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38132,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 96.67,,CLAIM ADJUSTMENT 3, 117.05,OTHER, 82.81, 188.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38133,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 179.75,OTHER, 126.51, 288.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38134,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.72,,CLAIM ADJUSTMENT 3, 158.52,OTHER, 109.46, 249.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38135,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 186.21,OTHER, 132.20, 301.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38136,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 50.93,,CLAIM ADJUSTMENT 3, 83.96,OTHER, 50.93, 144.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38137,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 216.78,,CLAIM ADJUSTMENT 3, 167.44,OTHER, 102.00, 232.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38138,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 216.78,,CLAIM ADJUSTMENT 3, 172.28,OTHER, 106.26, 242.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38139,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 87.35,,CLAIM ADJUSTMENT 3, 49.86,OTHER, 25.59, 87.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38140,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 85.51,,CLAIM ADJUSTMENT 3, 141.43,OTHER, 85.51, 242.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38141,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 69.71,OTHER, 45.42, 103.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38142,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 177.65,OTHER, 120.47, 274.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38143,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 189.46,OTHER, 130.87, 298.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38144,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 279.93,OTHER, 171.54, 479.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38145,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 265.00,OTHER, 171.54, 449.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38146,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 113.59,,CLAIM ADJUSTMENT 3, 149.90,OTHER, 108.18, 246.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38147,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.09,,CLAIM ADJUSTMENT 3, 167.02,OTHER, 46.09, 313.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38148,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.09,,CLAIM ADJUSTMENT 3, 76.10,OTHER, 46.09, 130.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38149,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.09,,CLAIM ADJUSTMENT 3, 147.35,OTHER, 46.09, 273.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38150,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 227.22,OTHER, 124.32, 396.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38151,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 295.49,OTHER, 124.32, 533.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38152,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 114.40,OTHER, 74.67, 170.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38153,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 155.48,OTHER, 110.85, 252.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38154,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38155,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38156,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38157,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 114.13,,CLAIM ADJUSTMENT 3, 36.72,OTHER, 8.41, 114.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38158,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 114.13,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 114.13, 360.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38159,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 114.13,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 114.13, 360.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38160,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 346.21,,CLAIM ADJUSTMENT 3, 526.62,OTHER, 346.21, 891.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38161,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 346.21,,CLAIM ADJUSTMENT 3, 290.83,OTHER, 143.52, 346.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38162,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38163,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 49.24,,CLAIM ADJUSTMENT 3, 162.12,OTHER, 49.24, 301.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38164,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 80.99,,CLAIM ADJUSTMENT 3, 140.39,OTHER, 80.99, 243.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38165,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 80.99,,CLAIM ADJUSTMENT 3, 140.39,OTHER, 80.99, 243.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38166,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 51.13,,CLAIM ADJUSTMENT 3, 166.97,OTHER, 51.13, 310.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38167,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 51.13,,CLAIM ADJUSTMENT 3, 54.96,OTHER, 37.67, 85.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38168,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 51.13,,CLAIM ADJUSTMENT 3, 86.43,OTHER, 51.13, 149.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38169,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 656.16,,CLAIM ADJUSTMENT 3, 950.56,OTHER, 656.16, 1594.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38170,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 656.16,,CLAIM ADJUSTMENT 3, 375.80,OTHER, 121.44, 656.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38171,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 545.72,OTHER, 384.68, 911.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38172,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 545.72,OTHER, 384.68, 911.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38173,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 278.85,OTHER, 121.44, 384.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38174,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 278.85,OTHER, 121.44, 384.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38175,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 591.97,OTHER, 225.62, 1080.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38176,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38177,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 96.59,,CLAIM ADJUSTMENT 3, 250.40,OTHER, 96.59, 456.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38178,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 96.59,,CLAIM ADJUSTMENT 3, 250.40,OTHER, 96.59, 456.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38179,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 157.67,,CLAIM ADJUSTMENT 3, 197.77,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38180,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 563.65,OTHER, 225.62, 1023.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38181,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38182,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 113.30,OTHER, 70.09, 159.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38183,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 113.30,OTHER, 70.09, 159.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38184,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38185,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38186,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 297.88,OTHER, 215.00, 490.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38187,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38188,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 262.11,OTHER, 141.55, 458.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38189,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 262.11,OTHER, 141.55, 458.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38190,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38191,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38192,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 673.61,OTHER, 225.62, 1244.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38193,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 673.61,OTHER, 225.62, 1244.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38194,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 383.08,OTHER, 225.62, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38195,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 673.61,OTHER, 225.62, 1244.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38196,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38197,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38198,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38199,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38200,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38201,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38202,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38203,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38204,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38205,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38206,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38207,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38208,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 655.39,OTHER, 225.62, 1207.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38209,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38210,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 284.89,,CLAIM ADJUSTMENT 3, 1042.14,OTHER, 284.89, 2539.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38211,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 284.89,,CLAIM ADJUSTMENT 3, 1042.14,OTHER, 284.89, 2539.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38212,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 184.77,OTHER, 39.56, 427.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38213,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 184.77,OTHER, 39.56, 427.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38214,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 138.71,,CLAIM ADJUSTMENT 3, 547.41,OTHER, 138.71, 1032.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38215,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 152.82,,CLAIM ADJUSTMENT 3, 154.36,OTHER, 103.88, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38216,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 152.82,,CLAIM ADJUSTMENT 3, 154.36,OTHER, 103.88, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38217,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 199.86,OTHER, 125.79, 286.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38218,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 199.86,OTHER, 125.79, 286.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38219,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 407.38,OTHER, 140.42, 864.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38220,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 407.38,OTHER, 140.42, 864.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38221,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 407.38,OTHER, 140.42, 864.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38222,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 332.46,OTHER, 140.42, 600.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38223,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 239.03,OTHER, 160.29, 365.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38224,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 239.03,OTHER, 160.29, 365.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38225,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 174.98,OTHER, 103.88, 239.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38226,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 136.10,OTHER, 76.16, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38227,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 140.33,OTHER, 74.39, 234.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38228,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 87.35,,CLAIM ADJUSTMENT 3, 228.33,OTHER, 87.35, 416.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38229,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38230,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38231,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 94.34,,CLAIM ADJUSTMENT 3, 182.46,OTHER, 94.34, 321.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38232,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 94.34,,CLAIM ADJUSTMENT 3, 182.46,OTHER, 94.34, 321.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38233,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 125.89,OTHER, 61.67, 234.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38234,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 125.89,OTHER, 61.67, 234.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38235,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 235.80,,CLAIM ADJUSTMENT 3, 415.63,OTHER, 235.80, 721.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38236,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 1853.96,OTHER, 1121.15, 3185.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38237,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 1853.96,OTHER, 1121.15, 3185.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38238,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 2171.37,OTHER, 1121.15, 3822.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38239,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 2171.37,OTHER, 1121.15, 3822.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38240,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 2171.37,OTHER, 1121.15, 3822.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38241,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 85.61,,CLAIM ADJUSTMENT 3, 152.82,OTHER, 85.61, 265.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38242,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 89.47,,CLAIM ADJUSTMENT 3, 165.98,OTHER, 89.47, 290.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38243,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.12,,CLAIM ADJUSTMENT 3, 260.74,OTHER, 110.12, 470.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38244,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.12,,CLAIM ADJUSTMENT 3, 260.74,OTHER, 110.12, 470.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38245,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 96.89,OTHER, 37.34, 176.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38246,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 96.89,OTHER, 37.34, 176.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38247,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 184.46,,CLAIM ADJUSTMENT 3, 323.07,OTHER, 184.46, 560.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38248,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 184.46,,CLAIM ADJUSTMENT 3, 323.07,OTHER, 184.46, 560.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38249,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 184.46,,CLAIM ADJUSTMENT 3, 323.07,OTHER, 184.46, 560.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38250,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 89.33,OTHER, 37.34, 161.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38251,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 89.33,OTHER, 37.34, 161.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38252,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 108.89,OTHER, 54.48, 192.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38253,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 108.89,OTHER, 54.48, 192.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38254,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38255,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38256,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 84.04,OTHER, 37.34, 150.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38257,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 84.04,OTHER, 37.34, 150.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38258,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 37.95,OTHER, 25.59, 58.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38259,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 37.95,OTHER, 25.59, 58.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38260,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 159.88,OTHER, 54.48, 294.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38261,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 159.88,OTHER, 54.48, 294.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38262,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 96.44,OTHER, 54.48, 167.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38263,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 96.44,OTHER, 54.48, 167.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38264,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38265,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38266,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.01,,CLAIM ADJUSTMENT 3, 47.95,OTHER, 21.01, 86.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38267,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 21.01,,CLAIM ADJUSTMENT 3, 47.95,OTHER, 21.01, 86.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38268,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 34.39,,CLAIM ADJUSTMENT 3, 55.33,OTHER, 34.39, 94.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38269,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 34.39,,CLAIM ADJUSTMENT 3, 55.33,OTHER, 34.39, 94.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38270,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.74,,CLAIM ADJUSTMENT 3, 58.74,OTHER, 29.74, 103.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38271,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.74,,CLAIM ADJUSTMENT 3, 58.74,OTHER, 29.74, 103.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38272,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 29.74,,CLAIM ADJUSTMENT 3, 58.74,OTHER, 29.74, 103.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38273,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 28.82,,CLAIM ADJUSTMENT 3, 142.33,OTHER, 28.82, 411.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38274,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 28.82,,CLAIM ADJUSTMENT 3, 142.33,OTHER, 28.82, 411.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38275,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 28.82,,CLAIM ADJUSTMENT 3, 72.71,OTHER, 28.82, 132.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38276,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 74.33,OTHER, 52.80, 120.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38277,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 74.33,OTHER, 52.80, 120.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38278,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 74.35,OTHER, 52.84, 120.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38279,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 69.01,,CLAIM ADJUSTMENT 3, 80.43,OTHER, 56.36, 128.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38280,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 69.01,,CLAIM ADJUSTMENT 3, 80.43,OTHER, 56.36, 128.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38281,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 69.01,,CLAIM ADJUSTMENT 3, 80.43,OTHER, 56.36, 128.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38282,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 60.80,OTHER, 40.91, 93.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38283,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 60.80,OTHER, 40.91, 93.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38284,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 61.55,,CLAIM ADJUSTMENT 3, 47.68,OTHER, 29.08, 66.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38285,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.96,,CLAIM ADJUSTMENT 3, 98.59,OTHER, 46.96, 175.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38286,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.96,,CLAIM ADJUSTMENT 3, 98.59,OTHER, 46.96, 175.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38287,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 46.96,,CLAIM ADJUSTMENT 3, 98.59,OTHER, 46.96, 175.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38288,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 44.87,,CLAIM ADJUSTMENT 3, 115.67,OTHER, 44.87, 210.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38289,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 44.87,,CLAIM ADJUSTMENT 3, 115.67,OTHER, 44.87, 210.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38290,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 44.87,,CLAIM ADJUSTMENT 3, 115.67,OTHER, 44.87, 210.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38291,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 55.58,,CLAIM ADJUSTMENT 3, 73.14,OTHER, 52.75, 120.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38292,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 55.58,,CLAIM ADJUSTMENT 3, 73.14,OTHER, 52.75, 120.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38293,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 55.58,,CLAIM ADJUSTMENT 3, 73.14,OTHER, 52.75, 120.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38294,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.13,,CLAIM ADJUSTMENT 3, 30.33,OTHER, 18.92, 43.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38295,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.21,,CLAIM ADJUSTMENT 3, 178.52,OTHER, 113.97, 259.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38296,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.21,,CLAIM ADJUSTMENT 3, 202.67,OTHER, 135.24, 308.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38297,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.21,,CLAIM ADJUSTMENT 3, 194.50,OTHER, 128.04, 291.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38298,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 142.50,,CLAIM ADJUSTMENT 3, 106.37,OTHER, 63.79, 145.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38299,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 208.14,,CLAIM ADJUSTMENT 3, 173.75,OTHER, 109.36, 249.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38300,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 208.14,,CLAIM ADJUSTMENT 3, 180.83,OTHER, 115.60, 263.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38301,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 208.14,,CLAIM ADJUSTMENT 3, 204.49,OTHER, 136.43, 310.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38302,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 143.15,,CLAIM ADJUSTMENT 3, 108.91,OTHER, 65.89, 150.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38303,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 41.16,,CLAIM ADJUSTMENT 3, 68.75,OTHER, 41.16, 118.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38304,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 41.16,,CLAIM ADJUSTMENT 3, 68.75,OTHER, 41.16, 118.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38305,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 41.16,,CLAIM ADJUSTMENT 3, 68.75,OTHER, 41.16, 118.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38306,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 44.69,OTHER, 31.56, 71.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38307,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 66.74,,CLAIM ADJUSTMENT 3, 78.22,OTHER, 54.89, 125.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38308,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 66.74,,CLAIM ADJUSTMENT 3, 78.22,OTHER, 54.89, 125.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38309,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 66.74,,CLAIM ADJUSTMENT 3, 59.17,OTHER, 38.11, 86.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38310,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 39.73,,CLAIM ADJUSTMENT 3, 66.10,OTHER, 39.73, 113.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38311,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 39.73,,CLAIM ADJUSTMENT 3, 66.10,OTHER, 39.73, 113.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38312,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 39.73,,CLAIM ADJUSTMENT 3, 66.10,OTHER, 39.73, 113.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38313,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 68.90,OTHER, 12.81, 151.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38314,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 96.26,,CLAIM ADJUSTMENT 3, 93.12,OTHER, 61.82, 140.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38315,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 84.59,,CLAIM ADJUSTMENT 3, 114.40,OTHER, 52.03, 259.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38316,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 84.59,,CLAIM ADJUSTMENT 3, 114.40,OTHER, 52.03, 259.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38317,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.23,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 53.32, 121.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38318,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.23,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 53.32, 121.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38319,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 105.23,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 53.32, 121.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38320,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38321,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38322,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38323,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38324,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38325,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38326,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38327,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38328,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38329,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38330,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 114.64,,CLAIM ADJUSTMENT 3, 145.27,OTHER, 103.88, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38331,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38332,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38333,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38334,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38335,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38336,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38337,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38338,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38339,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38340,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38341,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38342,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38343,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38344,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38345,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38346,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38347,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38348,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38349,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38350,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 103.66,,CLAIM ADJUSTMENT 3, 111.61,OTHER, 64.03, 142.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38351,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 164.56,,CLAIM ADJUSTMENT 3, 149.82,OTHER, 78.16, 173.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38352,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 247.58,,CLAIM ADJUSTMENT 3, 220.11,OTHER, 113.05, 250.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38353,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 149.74,OTHER, 77.35, 263.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38354,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 149.74,OTHER, 77.35, 263.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38355,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 156.74,OTHER, 77.35, 245.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38356,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 156.74,OTHER, 77.35, 245.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38357,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 233.57,OTHER, 127.82, 407.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38358,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 233.57,OTHER, 127.82, 407.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38359,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 197.91,OTHER, 127.82, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38360,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 197.91,OTHER, 127.82, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38361,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 369.55,OTHER, 203.96, 644.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38362,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 369.55,OTHER, 203.96, 644.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38363,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 247.74,OTHER, 150.14, 333.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38364,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 247.74,OTHER, 150.14, 333.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38365,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 580.80,OTHER, 324.71, 1010.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38366,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 580.80,OTHER, 324.71, 1010.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38367,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 332.53,OTHER, 185.91, 412.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38368,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 332.53,OTHER, 185.91, 412.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38369,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 479.76,,CLAIM ADJUSTMENT 3, 954.02,OTHER, 479.76, 1685.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38370,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 479.76,,CLAIM ADJUSTMENT 3, 954.02,OTHER, 479.76, 1685.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38371,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 479.76,,CLAIM ADJUSTMENT 3, 429.06,OTHER, 221.24, 490.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38372,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 720.78,,CLAIM ADJUSTMENT 3, 1514.86,OTHER, 720.78, 2695.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38373,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38374,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38375,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38376,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38377,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 167.97,OTHER, 113.31, 258.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38378,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 173.37,OTHER, 118.06, 269.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38379,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 179.18,OTHER, 123.17, 280.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38380,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 197.44,OTHER, 139.26, 317.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38381,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 192.88,OTHER, 135.24, 308.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38382,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38383,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38384,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 155.10,OTHER, 101.97, 232.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38385,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 162.99,OTHER, 108.92, 248.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38386,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 174.20,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38387,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 174.20,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38388,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 174.20,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38389,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 177.10,OTHER, 121.35, 276.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38390,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38391,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38392,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38393,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38394,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38395,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38396,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.74,,CLAIM ADJUSTMENT 3, 33.14,OTHER, 22.74, 51.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38397,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 30.74,,CLAIM ADJUSTMENT 3, 39.28,OTHER, 28.14, 64.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38398,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38399,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38400,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38401,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38402,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 101.33,,CLAIM ADJUSTMENT 3, 148.65,OTHER, 101.33, 249.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38403,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 133.36,,CLAIM ADJUSTMENT 3, 166.04,OTHER, 118.25, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38404,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38405,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38406,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 680.93,,CLAIM ADJUSTMENT 3, 350.13,OTHER, 165.55, 680.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38407,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 680.93,,CLAIM ADJUSTMENT 3, 350.13,OTHER, 165.55, 680.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38408,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1078.14,,CLAIM ADJUSTMENT 3, 553.11,OTHER, 261.01, 1078.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38409,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1078.14,,CLAIM ADJUSTMENT 3, 553.11,OTHER, 261.01, 1078.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38410,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 567.43,,CLAIM ADJUSTMENT 3, 308.45,OTHER, 152.65, 567.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38411,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 567.43,,CLAIM ADJUSTMENT 3, 308.45,OTHER, 152.65, 567.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38412,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 907.91,,CLAIM ADJUSTMENT 3, 466.19,OTHER, 220.16, 907.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38413,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 907.91,,CLAIM ADJUSTMENT 3, 466.19,OTHER, 220.16, 907.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38414,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38415,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38416,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38417,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38418,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38419,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38420,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38421,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1648.47,OTHER, 779.04, 2936.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38422,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1648.47,OTHER, 779.04, 2936.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38423,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1777.88,OTHER, 779.04, 3195.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38424,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1777.88,OTHER, 779.04, 3195.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38425,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1244.21,OTHER, 508.57, 2254.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38426,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1244.21,OTHER, 508.57, 2254.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38427,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1244.21,OTHER, 508.57, 2254.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38428,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1097.72,OTHER, 508.57, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38429,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1097.72,OTHER, 508.57, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38430,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1162.11,OTHER, 779.04, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38431,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1162.11,OTHER, 779.04, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38432,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1.66,,CLAIM ADJUSTMENT 3, 9.74,OTHER, 1.66, 18.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38433,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 63.90,OTHER, 37.34, 110.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38434,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 11.82,OTHER, 2.58, 37.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38435,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38436,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38437,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 33.71,,CLAIM ADJUSTMENT 3, 88.75,OTHER, 33.71, 162.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38438,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 33.71,,CLAIM ADJUSTMENT 3, 58.81,OTHER, 33.71, 101.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38439,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38440,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 231.89,OTHER, 165.06, 386.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38441,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 231.89,OTHER, 165.06, 386.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38442,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 35.44,OTHER, 18.28, 61.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38443,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 44.57,OTHER, 26.32, 61.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38444,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38445,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38446,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38447,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38448,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38449,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38450,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38451,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38452,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38453,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38454,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38455,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38456,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38457,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38458,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38459,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38460,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38461,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38462,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38463,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38464,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38465,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38466,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38467,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38468,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1597.44,,CLAIM ADJUSTMENT 3, 575.18,OTHER, 171.57, 1597.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38469,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2082.47,,CLAIM ADJUSTMENT 3, 690.66,OTHER, 171.57, 2082.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38470,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1937.50,,CLAIM ADJUSTMENT 3, 656.15,OTHER, 171.57, 1937.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38471,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 1734.01,,CLAIM ADJUSTMENT 3, 607.70,OTHER, 171.57, 1734.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38472,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 2065.06,,CLAIM ADJUSTMENT 3, 735.35,OTHER, 214.57, 2065.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38473,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 18.42,,CLAIM ADJUSTMENT 3, 421.89,OTHER, 18.42, 837.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38474,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38475,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38476,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38477,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38478,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38479,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38480,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38481,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38482,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38483,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38484,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38485,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38486,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38487,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38488,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38489,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38490,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38491,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38492,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38493,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38494,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38495,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38496,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38497,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38498,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38499,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38500,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38501,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38502,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38503,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38504,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38505,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38506,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38507,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38508,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38509,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38510,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38511,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 42.53,,CLAIM ADJUSTMENT 3, 62.01,OTHER, 42.53, 104.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38512,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38513,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38514,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38515,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38516,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38517,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38518,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38519,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38520,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38521,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38522,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38523,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38524,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38525,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38526,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38527,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38528,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38529,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38530,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38531,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38532,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38533,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38534,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38535,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38536,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38537,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38538,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38539,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38540,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38541,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38542,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38543,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38544,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38545,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38546,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38547,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38548,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38549,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38550,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38551,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38552,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38553,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38554,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38555,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38556,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38557,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38558,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38559,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38560,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38561,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38562,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38563,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38564,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38565,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38566,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38567,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38568,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38569,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38570,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38571,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38572,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38573,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38574,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38575,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38576,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38577,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38578,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38579,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38580,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38581,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38582,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38583,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38584,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38585,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38586,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38587,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38588,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38589,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38590,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38591,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38592,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38593,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38594,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38595,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38596,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38597,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38598,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38599,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38600,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38601,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38602,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38603,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38604,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38605,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38606,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38607,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38608,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38609,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38610,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38611,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38612,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38613,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38614,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38615,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38616,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38617,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38618,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38619,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38620,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38621,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38622,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38623,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38624,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38625,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38626,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38627,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38628,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38629,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38630,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38631,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38632,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38633,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38634,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38635,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38636,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38637,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38638,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38639,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38640,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38641,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38642,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38643,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38644,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,UNITED_TURQ_MEDICAID,BCBS NEW MEXICO TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 38645,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38646,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38647,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38648,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38649,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38650,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38651,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38652,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38653,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38654,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38655,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38656,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38657,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38658,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38659,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38660,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38661,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38662,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38663,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,WELLMED,WELLMED, 209.32,,OUTPAT REV HCPCS COMBO 1, 271.70,OTHER, 142.76, 477.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38664,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,WELLMED,WELLMED, 209.32,,OUTPAT REV HCPCS COMBO 1, 271.70,OTHER, 142.76, 477.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38665,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,WELLMED,WELLMED, 118.79,,OUTPAT REV HCPCS COMBO 1, 168.89,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38666,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38667,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,WELLMED,WELLMED, 211.23,,OUTPAT REV HCPCS COMBO 1, 273.87,OTHER, 142.76, 481.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38668,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38669,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,WELLMED,WELLMED, 155.70,,OUTPAT REV HCPCS COMBO 1, 242.16,OTHER, 155.70, 354.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38670,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38671,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38672,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38673,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38674,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38675,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38676,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38677,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38678,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38679,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38680,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38681,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38682,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38683,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38684,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38685,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38686,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38687,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38688,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38689,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38690,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38691,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38692,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38693,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38694,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38695,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38696,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38697,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38698,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38699,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38700,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38701,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38702,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38703,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38704,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38705,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38706,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38707,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38708,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38709,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38710,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38711,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38712,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38713,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,WELLMED,WELLMED, 145.30,,OUTPAT REV HCPCS COMBO 1, 185.53,OTHER, 86.20, 331.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38714,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38715,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38716,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38717,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38718,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38719,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38720,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,WELLMED,WELLMED, 165.01,,OUTPAT REV HCPCS COMBO 1, 278.63,OTHER, 165.01, 383.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38721,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,WELLMED,WELLMED, 296.20,,OUTPAT REV HCPCS COMBO 1, 427.61,OTHER, 296.20, 675.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38722,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,WELLMED,WELLMED, 179.25,,OUTPAT REV HCPCS COMBO 1, 237.66,OTHER, 143.26, 408.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38723,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,WELLMED,WELLMED, 193.33,,OUTPAT REV HCPCS COMBO 1, 253.66,OTHER, 143.26, 440.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38724,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,WELLMED,WELLMED, 209.63,,OUTPAT REV HCPCS COMBO 1, 272.17,OTHER, 143.26, 477.75,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38725,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,WELLMED,WELLMED, 191.34,,OUTPAT REV HCPCS COMBO 1, 251.39,OTHER, 143.26, 436.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38726,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38727,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,WELLMED,WELLMED, 202.93,,OUTPAT REV HCPCS COMBO 1, 264.56,OTHER, 143.26, 462.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38728,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,WELLMED,WELLMED, 204.98,,OUTPAT REV HCPCS COMBO 1, 306.35,OTHER, 204.98, 467.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38729,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38730,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38731,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,WELLMED,WELLMED, 230.23,,OUTPAT REV HCPCS COMBO 1, 293.08,OTHER, 132.82, 524.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38732,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,WELLMED,WELLMED, 836.72,,OUTPAT REV HCPCS COMBO 1, 1023.77,OTHER, 309.01, 1906.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38733,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38734,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,WELLMED,WELLMED, 1408.79,,OUTPAT REV HCPCS COMBO 1, 1703.49,OTHER, 435.32, 3210.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38735,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38736,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38737,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38738,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38739,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,WELLMED,WELLMED, 145.30,,OUTPAT REV HCPCS COMBO 1, 200.99,OTHER, 145.30, 331.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38740,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38741,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38742,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38743,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38744,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38745,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38746,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38747,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,WELLMED,WELLMED, 57.02,,OUTPAT REV HCPCS COMBO 1, 124.43,OTHER, 57.02, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38748,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,WELLMED,WELLMED, 53.32,,OUTPAT REV HCPCS COMBO 1, 120.23,OTHER, 53.32, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38749,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,WELLMED,WELLMED, 62.14,,OUTPAT REV HCPCS COMBO 1, 130.25,OTHER, 62.14, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38750,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,WELLMED,WELLMED, 62.14,,OUTPAT REV HCPCS COMBO 1, 130.25,OTHER, 62.14, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38751,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38752,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38753,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,WELLMED,WELLMED, 339.79,,OUTPAT REV HCPCS COMBO 1, 424.57,OTHER, 162.56, 774.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38754,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,WELLMED,WELLMED, 260.82,,OUTPAT REV HCPCS COMBO 1, 334.89,OTHER, 162.56, 594.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38755,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,WELLMED,WELLMED, 496.58,,OUTPAT REV HCPCS COMBO 1, 675.88,OTHER, 470.23, 1131.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38756,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,WELLMED,WELLMED, 406.01,,OUTPAT REV HCPCS COMBO 1, 499.77,OTHER, 162.56, 925.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38757,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,WELLMED,WELLMED, 406.01,,OUTPAT REV HCPCS COMBO 1, 499.77,OTHER, 162.56, 925.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38758,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,WELLMED,WELLMED, 148.80,,OUTPAT REV HCPCS COMBO 1, 207.69,OTHER, 148.80, 339.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38759,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,WELLMED,WELLMED, 148.80,,OUTPAT REV HCPCS COMBO 1, 207.69,OTHER, 148.80, 339.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38760,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,WELLMED,WELLMED, 133.93,,OUTPAT REV HCPCS COMBO 1, 176.70,OTHER, 103.34, 305.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38761,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,WELLMED,WELLMED, 485.88,,OUTPAT REV HCPCS COMBO 1, 596.69,OTHER, 188.66, 1107.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38762,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,WELLMED,WELLMED, 485.88,,OUTPAT REV HCPCS COMBO 1, 596.69,OTHER, 188.66, 1107.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38763,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,WELLMED,WELLMED, 845.35,,OUTPAT REV HCPCS COMBO 1, 1089.64,OTHER, 544.52, 1926.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38764,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,WELLMED,WELLMED, 15.05,,OUTPAT REV HCPCS COMBO 1, 22.43,OTHER, 15.05, 34.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38765,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,WELLMED,WELLMED, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38766,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,WELLMED,WELLMED, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38767,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,WELLMED,WELLMED, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38768,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,WELLMED,WELLMED, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38769,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,WELLMED,WELLMED, 13.35,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38770,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38771,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,WELLMED,WELLMED, 10.75,,OUTPAT REV HCPCS COMBO 1, 16.02,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38772,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,WELLMED,WELLMED, 440.37,,OUTPAT REV HCPCS COMBO 1, 579.04,OTHER, 331.58, 1003.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38773,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38774,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38775,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38776,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38777,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38778,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,WELLMED,WELLMED, 103.88,,OUTPAT REV HCPCS COMBO 1, 124.21,OTHER, 26.22, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38779,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,WELLMED,WELLMED, 103.88,,OUTPAT REV HCPCS COMBO 1, 124.21,OTHER, 26.22, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38780,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38781,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38782,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38783,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38784,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38785,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38786,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38787,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38788,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38789,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38790,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38791,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38792,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,WELLMED,WELLMED, 501.48,,OUTPAT REV HCPCS COMBO 1, 718.33,OTHER, 501.48, 1142.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38793,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38794,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38795,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38796,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38797,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38798,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38799,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38800,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38801,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38802,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38803,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38804,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38805,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38806,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38807,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38808,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38809,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38810,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38811,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38812,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38813,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38814,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38815,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38816,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38817,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38818,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,WELLMED,WELLMED, 173.27,,OUTPAT REV HCPCS COMBO 1, 242.39,OTHER, 173.27, 394.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38819,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,WELLMED,WELLMED, 173.27,,OUTPAT REV HCPCS COMBO 1, 242.39,OTHER, 173.27, 394.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38820,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38821,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED, 96.75,,OUTPAT REV HCPCS COMBO 1, 199.77,OTHER, 96.75, 377.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38822,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED, 96.75,,OUTPAT REV HCPCS COMBO 1, 266.50,OTHER, 96.75, 657.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38823,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,WELLMED,WELLMED, 1478.34,,OUTPAT REV HCPCS COMBO 1, 2146.91,OTHER, 1478.34, 3369.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38824,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,WELLMED,WELLMED, 1478.34,,OUTPAT REV HCPCS COMBO 1, 2146.91,OTHER, 1478.34, 3369.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38825,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,WELLMED,WELLMED, 482.83,,OUTPAT REV HCPCS COMBO 1, 719.65,OTHER, 482.83, 1100.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38826,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,WELLMED,WELLMED, 863.68,,OUTPAT REV HCPCS COMBO 1, 1287.31,OTHER, 863.68, 1968.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38827,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,WELLMED,WELLMED, 195.18,,OUTPAT REV HCPCS COMBO 1, 290.91,OTHER, 195.18, 444.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38828,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38829,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,WELLMED,WELLMED, 112.28,,OUTPAT REV HCPCS COMBO 1, 162.43,OTHER, 112.28, 255.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38830,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,WELLMED,WELLMED, 97.21,,OUTPAT REV HCPCS COMBO 1, 145.32,OTHER, 97.21, 221.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38831,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,WELLMED,WELLMED, 62.09,,OUTPAT REV HCPCS COMBO 1, 116.13,OTHER, 62.09, 191.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38832,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,WELLMED,WELLMED, 51.17,,OUTPAT REV HCPCS COMBO 1, 76.24,OTHER, 51.17, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38833,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,WELLMED,WELLMED, 91.62,,OUTPAT REV HCPCS COMBO 1, 124.60,OTHER, 86.34, 208.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38834,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38835,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WELLMED,WELLMED, 36.98,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38836,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38837,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,WELLMED,WELLMED, 58.91,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38838,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38839,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,WELLMED,WELLMED, 113.20,,OUTPAT REV HCPCS COMBO 1, 161.46,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38840,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38841,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WELLMED,WELLMED, 36.98,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38842,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38843,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,WELLMED,WELLMED, 122.45,,OUTPAT REV HCPCS COMBO 1, 171.96,OTHER, 122.45, 279.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38844,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38845,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,WELLMED,WELLMED, 94.39,,OUTPAT REV HCPCS COMBO 1, 127.74,OTHER, 86.34, 215.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38846,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38847,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,WELLMED,WELLMED, 137.97,,OUTPAT REV HCPCS COMBO 1, 189.58,OTHER, 137.97, 314.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38848,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38849,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,WELLMED,WELLMED, 84.85,,OUTPAT REV HCPCS COMBO 1, 116.92,OTHER, 84.85, 193.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38850,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38851,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,WELLMED,WELLMED, 234.79,,OUTPAT REV HCPCS COMBO 1, 299.54,OTHER, 138.19, 535.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38852,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38853,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,WELLMED,WELLMED, 165.67,,OUTPAT REV HCPCS COMBO 1, 221.04,OTHER, 138.19, 377.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38854,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38855,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,WELLMED,WELLMED, 127.28,,OUTPAT REV HCPCS COMBO 1, 177.44,OTHER, 127.28, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38856,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38857,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,WELLMED,WELLMED, 44.60,,OUTPAT REV HCPCS COMBO 1, 71.21,OTHER, 44.60, 101.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38858,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38859,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,WELLMED,WELLMED, 152.34,,OUTPAT REV HCPCS COMBO 1, 193.56,OTHER, 86.34, 347.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38860,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38861,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,WELLMED,WELLMED, 178.71,,OUTPAT REV HCPCS COMBO 1, 223.50,OTHER, 86.34, 407.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38862,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,WELLMED,WELLMED, 1259.10,,OUTPAT REV HCPCS COMBO 1, 1313.91,OTHER, 283.82, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38863,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,WELLMED,WELLMED, 935.89,,OUTPAT REV HCPCS COMBO 1, 1313.91,OTHER, 283.82, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38864,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38865,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38866,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,WELLMED,WELLMED, 962.60,,OUTPAT REV HCPCS COMBO 1, 1196.04,OTHER, 432.18, 2193.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38867,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,WELLMED,WELLMED, 962.60,,OUTPAT REV HCPCS COMBO 1, 1196.04,OTHER, 432.18, 2193.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38868,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38869,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38870,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,WELLMED,WELLMED, 1259.10,,OUTPAT REV HCPCS COMBO 1, 1545.39,OTHER, 485.27, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38871,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,WELLMED,WELLMED, 1259.10,,OUTPAT REV HCPCS COMBO 1, 1545.39,OTHER, 485.27, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38872,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38873,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38874,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,WELLMED,WELLMED, 781.62,,OUTPAT REV HCPCS COMBO 1, 955.20,OTHER, 283.82, 1781.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38875,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38876,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,WELLMED,WELLMED, 518.18,,OUTPAT REV HCPCS COMBO 1, 691.35,OTHER, 432.18, 1180.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38877,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38878,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,WELLMED,WELLMED, 679.40,,OUTPAT REV HCPCS COMBO 1, 887.08,OTHER, 485.27, 1548.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38879,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38880,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,WELLMED,WELLMED, 734.01,,OUTPAT REV HCPCS COMBO 1, 901.22,OTHER, 283.82, 1673.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38881,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,WELLMED,WELLMED, 734.17,,OUTPAT REV HCPCS COMBO 1, 901.22,OTHER, 283.82, 1673.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38882,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38883,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38884,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,WELLMED,WELLMED, 839.22,,OUTPAT REV HCPCS COMBO 1, 1055.93,OTHER, 432.18, 1912.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38885,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,WELLMED,WELLMED, 1056.51,,OUTPAT REV HCPCS COMBO 1, 1302.68,OTHER, 432.18, 2407.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38886,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38887,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38888,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,WELLMED,WELLMED, 350.02,,OUTPAT REV HCPCS COMBO 1, 513.03,OTHER, 350.02, 797.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38889,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38890,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,WELLMED,WELLMED, 1076.96,,OUTPAT REV HCPCS COMBO 1, 1290.59,OTHER, 283.82, 2454.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38891,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38892,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,WELLMED,WELLMED, 1120.02,,OUTPAT REV HCPCS COMBO 1, 1374.81,OTHER, 432.18, 2552.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38893,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38894,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,WELLMED,WELLMED, 1013.04,,OUTPAT REV HCPCS COMBO 1, 1265.96,OTHER, 485.27, 2308.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38895,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38896,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,WELLMED,WELLMED, 843.77,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38897,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,WELLMED,WELLMED, 843.77,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38898,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,WELLMED,WELLMED, 843.77,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38899,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38900,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38901,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38902,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,WELLMED,WELLMED, 1015.19,,OUTPAT REV HCPCS COMBO 1, 1270.81,OTHER, 495.38, 2313.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38903,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38904,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,WELLMED,WELLMED, 1317.38,,OUTPAT REV HCPCS COMBO 1, 1681.52,OTHER, 779.04, 3002.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38905,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38906,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,WELLMED,WELLMED, 971.97,,OUTPAT REV HCPCS COMBO 1, 1224.87,OTHER, 508.57, 2215.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38907,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38908,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,WELLMED,WELLMED, 1036.73,,OUTPAT REV HCPCS COMBO 1, 1324.21,OTHER, 616.91, 2362.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38909,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38910,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,WELLMED,WELLMED, 1186.59,,OUTPAT REV HCPCS COMBO 1, 1532.99,OTHER, 779.04, 2704.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38911,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38912,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,WELLMED,WELLMED, 979.65,,OUTPAT REV HCPCS COMBO 1, 1233.59,OTHER, 508.57, 2232.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38913,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38914,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,WELLMED,WELLMED, 976.96,,OUTPAT REV HCPCS COMBO 1, 1256.33,OTHER, 616.91, 2226.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38915,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38916,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,WELLMED,WELLMED, 1123.27,,OUTPAT REV HCPCS COMBO 1, 1461.09,OTHER, 779.04, 2560.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38917,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38918,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,WELLMED,WELLMED, 1138.21,,OUTPAT REV HCPCS COMBO 1, 1413.66,OTHER, 508.57, 2594.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38919,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38920,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,WELLMED,WELLMED, 1757.38,,OUTPAT REV HCPCS COMBO 1, 2181.19,OTHER, 779.04, 4005.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38921,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,WELLMED,WELLMED, 1757.38,,OUTPAT REV HCPCS COMBO 1, 2181.19,OTHER, 779.04, 4005.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38922,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38923,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38924,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WELLMED,WELLMED, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38925,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WELLMED,WELLMED, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38926,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WELLMED,WELLMED, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38927,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WELLMED,WELLMED, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38928,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38929,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38930,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38931,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38932,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WELLMED,WELLMED, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38933,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38934,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WELLMED,WELLMED, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38935,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WELLMED,WELLMED, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38936,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38937,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38938,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,WELLMED,WELLMED, 195.04,,OUTPAT REV HCPCS COMBO 1, 242.05,OTHER, 86.34, 444.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38939,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,WELLMED,WELLMED, 196.33,,OUTPAT REV HCPCS COMBO 1, 243.52,OTHER, 86.34, 447.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38940,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38941,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38942,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,WELLMED,WELLMED, 159.59,,OUTPAT REV HCPCS COMBO 1, 214.14,OTHER, 138.19, 363.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38943,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,WELLMED,WELLMED, 182.39,,OUTPAT REV HCPCS COMBO 1, 240.03,OTHER, 138.19, 415.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38944,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38945,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38946,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,WELLMED,WELLMED, 190.18,,OUTPAT REV HCPCS COMBO 1, 248.87,OTHER, 138.19, 433.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38947,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38948,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,WELLMED,WELLMED, 127.28,,OUTPAT REV HCPCS COMBO 1, 165.10,OTHER, 86.34, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38949,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38950,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WELLMED,WELLMED, 36.98,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38951,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38952,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WELLMED,WELLMED, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38953,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WELLMED,WELLMED, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38954,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WELLMED,WELLMED, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38955,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38956,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38957,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WELLMED,WELLMED, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1356.87,OTHER, 432.18, 2737.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38958,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,WELLMED,WELLMED, 1201.21,,OUTPAT REV HCPCS COMBO 1, 1356.87,OTHER, 432.18, 2737.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38959,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38960,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,WELLMED,WELLMED, 1498.49,,OUTPAT REV HCPCS COMBO 1, 1817.25,OTHER, 485.27, 3415.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38961,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38962,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WELLMED,WELLMED, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38963,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WELLMED,WELLMED, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38964,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WELLMED,WELLMED, 1007.23,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38965,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38966,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38967,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38968,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,WELLMED,WELLMED, 2141.41,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38969,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,WELLMED,WELLMED, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38970,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,WELLMED,WELLMED, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38971,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,WELLMED,WELLMED, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38972,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,WELLMED,WELLMED, 1442.94,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38973,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38974,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38975,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38976,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38977,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,WELLMED,WELLMED, 544.38,,OUTPAT REV HCPCS COMBO 1, 1310.99,OTHER, 544.38, 2768.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38978,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,WELLMED,WELLMED, 1214.75,,OUTPAT REV HCPCS COMBO 1, 1310.99,OTHER, 544.38, 2768.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38979,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38980,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38981,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,WELLMED,WELLMED, 130.72,,OUTPAT REV HCPCS COMBO 1, 169.01,OTHER, 86.34, 297.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38982,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,WELLMED,WELLMED, 130.72,,OUTPAT REV HCPCS COMBO 1, 169.01,OTHER, 86.34, 297.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38983,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38984,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38985,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,WELLMED,WELLMED, 189.11,,OUTPAT REV HCPCS COMBO 1, 247.65,OTHER, 138.19, 430.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38986,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38987,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,WELLMED,WELLMED, 279.76,,OUTPAT REV HCPCS COMBO 1, 350.60,OTHER, 138.19, 637.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38988,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38989,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,WELLMED,WELLMED, 307.96,,OUTPAT REV HCPCS COMBO 1, 382.63,OTHER, 138.19, 701.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38990,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38991,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,WELLMED,WELLMED, 229.47,,OUTPAT REV HCPCS COMBO 1, 293.50,OTHER, 138.19, 522.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38992,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38993,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,WELLMED,WELLMED, 205.14,,OUTPAT REV HCPCS COMBO 1, 265.86,OTHER, 138.19, 467.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38994,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38995,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,WELLMED,WELLMED, 113.20,,OUTPAT REV HCPCS COMBO 1, 161.46,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38996,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38997,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,WELLMED,WELLMED, 107.50,,OUTPAT REV HCPCS COMBO 1, 142.64,OTHER, 86.34, 245.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 38998,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 38999,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,WELLMED,WELLMED, 36.98,,OUTPAT REV HCPCS COMBO 1, 63.06,OTHER, 36.98, 88.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39000,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,WELLMED,WELLMED, 113.20,,OUTPAT REV HCPCS COMBO 1, 163.44,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39001,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39002,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,WELLMED,WELLMED, 199.31,,OUTPAT REV HCPCS COMBO 1, 259.24,OTHER, 138.19, 454.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39003,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39004,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,WELLMED,WELLMED, 118.00,,OUTPAT REV HCPCS COMBO 1, 166.91,OTHER, 118.00, 268.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39005,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39006,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,WELLMED,WELLMED, 329.50,,OUTPAT REV HCPCS COMBO 1, 407.08,OTHER, 138.19, 750.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39007,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39008,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,WELLMED,WELLMED, 1225.59,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39009,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,WELLMED,WELLMED, 1225.59,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39010,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,WELLMED,WELLMED, 1225.59,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39011,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39012,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39013,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39014,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,WELLMED,WELLMED, 483.75,,OUTPAT REV HCPCS COMBO 1, 664.89,OTHER, 483.75, 1102.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39015,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39016,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,WELLMED,WELLMED, 1392.67,,OUTPAT REV HCPCS COMBO 1, 1649.11,OTHER, 283.82, 3173.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39017,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,WELLMED,WELLMED, 1392.67,,OUTPAT REV HCPCS COMBO 1, 1649.11,OTHER, 283.82, 3173.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39018,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39019,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39020,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,WELLMED,WELLMED, 1376.00,,OUTPAT REV HCPCS COMBO 1, 1665.51,OTHER, 432.18, 3136.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39021,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39022,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,WELLMED,WELLMED, 1207.81,,OUTPAT REV HCPCS COMBO 1, 1439.18,OTHER, 283.82, 2752.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39023,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39024,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,WELLMED,WELLMED, 1364.62,,OUTPAT REV HCPCS COMBO 1, 1652.58,OTHER, 432.18, 3110.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39025,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39026,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,WELLMED,WELLMED, 1290.00,,OUTPAT REV HCPCS COMBO 1, 1580.48,OTHER, 485.27, 2940.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39027,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39028,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,WELLMED,WELLMED, 1401.19,,OUTPAT REV HCPCS COMBO 1, 1712.29,OTHER, 508.57, 3193.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39029,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39030,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,WELLMED,WELLMED, 1561.88,,OUTPAT REV HCPCS COMBO 1, 1894.78,OTHER, 508.57, 3559.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39031,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39032,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,WELLMED,WELLMED, 1370.93,,OUTPAT REV HCPCS COMBO 1, 1677.93,OTHER, 508.57, 3124.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39033,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39034,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,WELLMED,WELLMED, 1703.32,,OUTPAT REV HCPCS COMBO 1, 2119.80,OTHER, 779.04, 3881.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39035,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39036,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,WELLMED,WELLMED, 2072.93,,OUTPAT REV HCPCS COMBO 1, 2539.54,OTHER, 779.04, 4724.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39037,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39038,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,WELLMED,WELLMED, 1941.42,,OUTPAT REV HCPCS COMBO 1, 2390.20,OTHER, 779.04, 4424.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39039,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39040,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39041,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39042,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39043,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,WELLMED,WELLMED, 179.56,,OUTPAT REV HCPCS COMBO 1, 236.81,OTHER, 138.19, 409.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39044,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39045,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,WELLMED,WELLMED, 141.74,,OUTPAT REV HCPCS COMBO 1, 193.87,OTHER, 138.19, 323.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39046,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39047,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,WELLMED,WELLMED, 1051.04,,OUTPAT REV HCPCS COMBO 1, 1261.16,OTHER, 283.82, 2395.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39048,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,WELLMED,WELLMED, 1051.04,,OUTPAT REV HCPCS COMBO 1, 1261.16,OTHER, 283.82, 2395.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39049,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39050,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39051,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,WELLMED,WELLMED, 1015.49,,OUTPAT REV HCPCS COMBO 1, 1256.10,OTHER, 432.18, 2314.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39052,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39053,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,WELLMED,WELLMED, 686.07,,OUTPAT REV HCPCS COMBO 1, 894.65,OTHER, 485.27, 1563.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39054,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39055,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,WELLMED,WELLMED, 1435.73,,OUTPAT REV HCPCS COMBO 1, 1751.53,OTHER, 508.57, 3272.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39056,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39057,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,WELLMED,WELLMED, 2152.02,,OUTPAT REV HCPCS COMBO 1, 2629.35,OTHER, 779.04, 4904.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39058,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39059,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,WELLMED,WELLMED, 860.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39060,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,WELLMED,WELLMED, 860.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39061,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,WELLMED,WELLMED, 860.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39062,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39063,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39064,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39065,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,WELLMED,WELLMED, 126.48,,OUTPAT REV HCPCS COMBO 1, 164.19,OTHER, 86.34, 288.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39066,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39067,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,WELLMED,WELLMED, 179.46,,OUTPAT REV HCPCS COMBO 1, 224.35,OTHER, 86.34, 408.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39068,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39069,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,WELLMED,WELLMED, 165.68,,OUTPAT REV HCPCS COMBO 1, 208.71,OTHER, 86.34, 377.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39070,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,WELLMED,WELLMED, 165.68,,OUTPAT REV HCPCS COMBO 1, 208.71,OTHER, 86.34, 377.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39071,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,WELLMED,WELLMED, 171.85,,OUTPAT REV HCPCS COMBO 1, 215.71,OTHER, 86.34, 391.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39072,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39073,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39074,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39075,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,WELLMED,WELLMED, 113.20,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39076,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,WELLMED,WELLMED, 113.20,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39077,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,WELLMED,WELLMED, 113.20,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39078,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39079,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39080,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39081,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,WELLMED,WELLMED, 136.74,,OUTPAT REV HCPCS COMBO 1, 175.84,OTHER, 86.34, 311.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39082,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,WELLMED,WELLMED, 130.77,,OUTPAT REV HCPCS COMBO 1, 169.06,OTHER, 86.34, 298.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39083,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,WELLMED,WELLMED, 130.77,,OUTPAT REV HCPCS COMBO 1, 169.06,OTHER, 86.34, 298.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39084,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39085,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39086,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39087,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,WELLMED,WELLMED, 178.02,,OUTPAT REV HCPCS COMBO 1, 235.06,OTHER, 138.19, 405.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39088,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,WELLMED,WELLMED, 178.02,,OUTPAT REV HCPCS COMBO 1, 235.06,OTHER, 138.19, 405.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39089,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,WELLMED,WELLMED, 182.68,,OUTPAT REV HCPCS COMBO 1, 240.36,OTHER, 138.19, 416.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39090,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39091,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39092,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39093,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,WELLMED,WELLMED, 175.36,,OUTPAT REV HCPCS COMBO 1, 219.70,OTHER, 86.34, 399.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39094,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,WELLMED,WELLMED, 170.74,,OUTPAT REV HCPCS COMBO 1, 214.45,OTHER, 86.34, 389.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39095,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,WELLMED,WELLMED, 170.74,,OUTPAT REV HCPCS COMBO 1, 214.45,OTHER, 86.34, 389.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39096,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39097,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39098,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39099,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,WELLMED,WELLMED, 163.79,,OUTPAT REV HCPCS COMBO 1, 206.56,OTHER, 86.34, 373.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39100,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,WELLMED,WELLMED, 168.41,,OUTPAT REV HCPCS COMBO 1, 211.81,OTHER, 86.34, 383.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39101,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,WELLMED,WELLMED, 163.79,,OUTPAT REV HCPCS COMBO 1, 206.56,OTHER, 86.34, 373.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39102,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39103,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39104,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39105,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,WELLMED,WELLMED, 184.47,,OUTPAT REV HCPCS COMBO 1, 230.04,OTHER, 86.34, 420.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39106,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,WELLMED,WELLMED, 178.71,,OUTPAT REV HCPCS COMBO 1, 223.50,OTHER, 86.34, 407.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39107,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39108,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39109,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39110,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,WELLMED,WELLMED, 185.16,,OUTPAT REV HCPCS COMBO 1, 230.83,OTHER, 86.34, 421.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39111,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,WELLMED,WELLMED, 185.16,,OUTPAT REV HCPCS COMBO 1, 230.83,OTHER, 86.34, 421.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39112,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,WELLMED,WELLMED, 190.92,,OUTPAT REV HCPCS COMBO 1, 237.37,OTHER, 86.34, 435.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39113,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39114,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39115,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39116,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,WELLMED,WELLMED, 58.91,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39117,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,WELLMED,WELLMED, 81.70,,OUTPAT REV HCPCS COMBO 1, 125.68,OTHER, 81.70, 186.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39118,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,WELLMED,WELLMED, 58.91,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39119,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39120,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39121,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39122,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,WELLMED,WELLMED, 170.11,,OUTPAT REV HCPCS COMBO 1, 213.73,OTHER, 86.34, 387.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39123,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,WELLMED,WELLMED, 164.82,,OUTPAT REV HCPCS COMBO 1, 207.73,OTHER, 86.34, 375.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39124,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,WELLMED,WELLMED, 164.83,,OUTPAT REV HCPCS COMBO 1, 207.74,OTHER, 86.34, 375.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39125,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39126,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39127,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39128,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,WELLMED,WELLMED, 191.64,,OUTPAT REV HCPCS COMBO 1, 238.18,OTHER, 86.34, 436.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39129,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,WELLMED,WELLMED, 196.26,,OUTPAT REV HCPCS COMBO 1, 243.44,OTHER, 86.34, 447.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39130,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,WELLMED,WELLMED, 191.64,,OUTPAT REV HCPCS COMBO 1, 238.18,OTHER, 86.34, 436.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39131,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39132,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39133,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39134,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,WELLMED,WELLMED, 181.03,,OUTPAT REV HCPCS COMBO 1, 238.48,OTHER, 138.19, 412.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39135,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,WELLMED,WELLMED, 175.27,,OUTPAT REV HCPCS COMBO 1, 231.94,OTHER, 138.19, 399.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39136,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,WELLMED,WELLMED, 175.27,,OUTPAT REV HCPCS COMBO 1, 231.94,OTHER, 138.19, 399.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39137,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39138,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39139,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39140,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,WELLMED,WELLMED, 175.94,,OUTPAT REV HCPCS COMBO 1, 220.36,OTHER, 86.34, 400.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39141,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,WELLMED,WELLMED, 175.99,,OUTPAT REV HCPCS COMBO 1, 220.42,OTHER, 86.34, 401.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39142,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,WELLMED,WELLMED, 180.62,,OUTPAT REV HCPCS COMBO 1, 225.67,OTHER, 86.34, 411.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39143,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39144,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39145,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39146,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,WELLMED,WELLMED, 146.59,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39147,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,WELLMED,WELLMED, 135.73,,OUTPAT REV HCPCS COMBO 1, 174.69,OTHER, 86.34, 309.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39148,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WELLMED,WELLMED, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39149,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,WELLMED,WELLMED, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39150,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WELLMED,WELLMED, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39151,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,WELLMED,WELLMED, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39152,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WELLMED,WELLMED, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39153,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,WELLMED,WELLMED, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39154,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WELLMED,WELLMED, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39155,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WELLMED,WELLMED, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39156,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,WELLMED,WELLMED, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39157,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WELLMED,WELLMED, 131.11,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39158,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,WELLMED,WELLMED, 131.11,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39159,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39160,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39161,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39162,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39163,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39164,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39165,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39166,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39167,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39168,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39169,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39170,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39171,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39172,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,WELLMED,WELLMED, 813.42,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39173,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,WELLMED,WELLMED, 874.84,,OUTPAT REV HCPCS COMBO 1, 1061.06,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39174,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,WELLMED,WELLMED, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39175,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,WELLMED,WELLMED, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39176,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,WELLMED,WELLMED, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39177,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,WELLMED,WELLMED, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39178,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,WELLMED,WELLMED, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39179,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,WELLMED,WELLMED, 287.67,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39180,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,WELLMED,WELLMED, 287.67,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39181,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,WELLMED,WELLMED, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39182,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,WELLMED,WELLMED, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39183,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,WELLMED,WELLMED, 287.67,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39184,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,WELLMED,WELLMED, 874.84,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39185,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,WELLMED,WELLMED, 874.84,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39186,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,WELLMED,WELLMED, 813.42,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39187,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39188,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39189,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39190,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39191,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39192,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39193,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39194,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39195,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39196,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39197,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39198,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39199,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39200,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39201,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,WELLMED,WELLMED, 1216.47,,OUTPAT REV HCPCS COMBO 1, 1484.34,OTHER, 432.18, 2772.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39202,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,WELLMED,WELLMED, 1216.47,,OUTPAT REV HCPCS COMBO 1, 1484.34,OTHER, 432.18, 2772.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39203,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39204,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39205,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39206,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,WELLMED,WELLMED, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39207,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,WELLMED,WELLMED, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39208,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39209,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39210,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,WELLMED,WELLMED, 822.87,,OUTPAT REV HCPCS COMBO 1, 1055.55,OTHER, 508.57, 1875.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39211,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39212,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,WELLMED,WELLMED, 1419.11,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39213,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,WELLMED,WELLMED, 1419.11,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39214,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,WELLMED,WELLMED, 1419.11,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39215,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39216,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39217,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39218,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WELLMED,WELLMED, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39219,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WELLMED,WELLMED, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39220,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WELLMED,WELLMED, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39221,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WELLMED,WELLMED, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39222,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WELLMED,WELLMED, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39223,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WELLMED,WELLMED, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39224,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WELLMED,WELLMED, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39225,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WELLMED,WELLMED, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39226,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WELLMED,WELLMED, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39227,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WELLMED,WELLMED, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39228,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WELLMED,WELLMED, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39229,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WELLMED,WELLMED, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39230,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WELLMED,WELLMED, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39231,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WELLMED,WELLMED, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39232,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WELLMED,WELLMED, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39233,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WELLMED,WELLMED, 1446.81,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39234,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39235,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39236,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39237,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39238,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39239,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39240,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39241,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39242,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39243,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39244,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39245,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39246,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39247,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39248,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39249,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39250,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,WELLMED,WELLMED, 1113.81,,OUTPAT REV HCPCS COMBO 1, 1450.34,OTHER, 779.04, 2538.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39251,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,WELLMED,WELLMED, 1113.81,,OUTPAT REV HCPCS COMBO 1, 1450.34,OTHER, 779.04, 2538.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39252,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39253,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39254,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39255,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39256,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39257,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39258,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,WELLMED,WELLMED, 154.92,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39259,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,WELLMED,WELLMED, 154.92,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39260,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,WELLMED,WELLMED, 154.92,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39261,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39262,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39263,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39264,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,WELLMED,WELLMED, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39265,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,WELLMED,WELLMED, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39266,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,WELLMED,WELLMED, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39267,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,WELLMED,WELLMED, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39268,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,WELLMED,WELLMED, 149.63,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39269,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39270,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39271,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39272,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39273,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,WELLMED,WELLMED, 195.73,,OUTPAT REV HCPCS COMBO 1, 234.40,OTHER, 146.51, 446.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39274,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,WELLMED,WELLMED, 155.65,,OUTPAT REV HCPCS COMBO 1, 234.40,OTHER, 146.51, 446.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39275,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39276,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39277,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,WELLMED,WELLMED, 160.19,,OUTPAT REV HCPCS COMBO 1, 202.98,OTHER, 88.46, 365.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39278,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,WELLMED,WELLMED, 160.19,,OUTPAT REV HCPCS COMBO 1, 202.98,OTHER, 88.46, 365.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39279,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,WELLMED,WELLMED, 164.81,,OUTPAT REV HCPCS COMBO 1, 208.23,OTHER, 88.46, 375.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39280,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39281,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39282,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39283,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,WELLMED,WELLMED, 167.46,,OUTPAT REV HCPCS COMBO 1, 210.73,OTHER, 86.34, 381.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39284,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,WELLMED,WELLMED, 162.18,,OUTPAT REV HCPCS COMBO 1, 204.73,OTHER, 86.34, 369.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39285,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,WELLMED,WELLMED, 162.18,,OUTPAT REV HCPCS COMBO 1, 204.73,OTHER, 86.34, 369.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39286,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39287,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39288,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39289,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,WELLMED,WELLMED, 208.05,,OUTPAT REV HCPCS COMBO 1, 269.16,OTHER, 138.19, 474.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39290,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,WELLMED,WELLMED, 212.67,,OUTPAT REV HCPCS COMBO 1, 274.41,OTHER, 138.19, 484.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39291,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,WELLMED,WELLMED, 208.05,,OUTPAT REV HCPCS COMBO 1, 269.16,OTHER, 138.19, 474.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39292,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39293,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39294,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39295,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,WELLMED,WELLMED, 325.08,,OUTPAT REV HCPCS COMBO 1, 402.07,OTHER, 138.19, 740.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39296,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,WELLMED,WELLMED, 319.17,,OUTPAT REV HCPCS COMBO 1, 395.36,OTHER, 138.19, 727.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39297,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,WELLMED,WELLMED, 319.17,,OUTPAT REV HCPCS COMBO 1, 395.36,OTHER, 138.19, 727.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39298,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39299,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39300,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39301,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,WELLMED,WELLMED, 116.95,,OUTPAT REV HCPCS COMBO 1, 153.37,OTHER, 86.34, 266.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39302,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39303,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,WELLMED,WELLMED, 195.94,,OUTPAT REV HCPCS COMBO 1, 243.07,OTHER, 86.34, 446.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39304,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,WELLMED,WELLMED, 191.32,,OUTPAT REV HCPCS COMBO 1, 237.82,OTHER, 86.34, 436.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39305,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,WELLMED,WELLMED, 191.32,,OUTPAT REV HCPCS COMBO 1, 237.82,OTHER, 86.34, 436.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39306,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39307,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39308,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39309,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,WELLMED,WELLMED, 36.98,,OUTPAT REV HCPCS COMBO 1, 74.90,OTHER, 36.98, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39310,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,WELLMED,WELLMED, 36.98,,OUTPAT REV HCPCS COMBO 1, 74.90,OTHER, 36.98, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39311,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,WELLMED,WELLMED, 73.96,,OUTPAT REV HCPCS COMBO 1, 116.89,OTHER, 73.96, 168.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39312,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39313,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39314,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39315,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,WELLMED,WELLMED, 163.83,,OUTPAT REV HCPCS COMBO 1, 218.95,OTHER, 138.19, 373.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39316,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,WELLMED,WELLMED, 163.83,,OUTPAT REV HCPCS COMBO 1, 218.95,OTHER, 138.19, 373.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39317,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,WELLMED,WELLMED, 169.42,,OUTPAT REV HCPCS COMBO 1, 225.30,OTHER, 138.19, 386.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39318,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39319,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39320,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39321,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,WELLMED,WELLMED, 185.33,,OUTPAT REV HCPCS COMBO 1, 243.37,OTHER, 138.19, 422.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39322,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,WELLMED,WELLMED, 179.52,,OUTPAT REV HCPCS COMBO 1, 236.76,OTHER, 138.19, 409.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39323,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,WELLMED,WELLMED, 179.52,,OUTPAT REV HCPCS COMBO 1, 236.76,OTHER, 138.19, 409.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39324,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39325,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39326,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39327,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,WELLMED,WELLMED, 146.18,,OUTPAT REV HCPCS COMBO 1, 186.56,OTHER, 86.34, 333.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39328,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,WELLMED,WELLMED, 146.18,,OUTPAT REV HCPCS COMBO 1, 186.56,OTHER, 86.34, 333.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39329,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39330,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39331,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,WELLMED,WELLMED, 202.21,,OUTPAT REV HCPCS COMBO 1, 250.19,OTHER, 86.34, 460.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39332,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,WELLMED,WELLMED, 197.50,,OUTPAT REV HCPCS COMBO 1, 244.84,OTHER, 86.34, 450.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39333,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,WELLMED,WELLMED, 197.59,,OUTPAT REV HCPCS COMBO 1, 244.94,OTHER, 86.34, 450.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39334,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39335,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39336,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39337,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,WELLMED,WELLMED, 100.19,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39338,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,WELLMED,WELLMED, 100.19,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39339,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,WELLMED,WELLMED, 100.19,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39340,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39341,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39342,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39343,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,WELLMED,WELLMED, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39344,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,WELLMED,WELLMED, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39345,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,WELLMED,WELLMED, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39346,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,WELLMED,WELLMED, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39347,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,WELLMED,WELLMED, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39348,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,WELLMED,WELLMED, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39349,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,WELLMED,WELLMED, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39350,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,WELLMED,WELLMED, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39351,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED, 139.75,,OUTPAT REV HCPCS COMBO 1, 179.26,OTHER, 86.34, 318.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39352,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,WELLMED,WELLMED, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39353,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,WELLMED,WELLMED, 133.79,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39354,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39355,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39356,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39357,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39358,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39359,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39360,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39361,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39362,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39363,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39364,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39365,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WELLMED,WELLMED, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39366,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,WELLMED,WELLMED, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39367,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,WELLMED,WELLMED, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39368,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,WELLMED,WELLMED, 991.15,,OUTPAT REV HCPCS COMBO 1, 1193.14,OTHER, 283.82, 2258.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39369,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WELLMED,WELLMED, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39370,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,WELLMED,WELLMED, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39371,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WELLMED,WELLMED, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39372,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,WELLMED,WELLMED, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39373,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WELLMED,WELLMED, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39374,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,WELLMED,WELLMED, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39375,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WELLMED,WELLMED, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39376,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,WELLMED,WELLMED, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39377,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WELLMED,WELLMED, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39378,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,WELLMED,WELLMED, 985.54,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39379,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39380,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39381,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39382,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39383,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39384,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39385,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39386,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39387,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39388,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39389,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39390,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39391,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39392,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39393,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,WELLMED,WELLMED, 1173.04,,OUTPAT REV HCPCS COMBO 1, 1435.02,OTHER, 432.18, 2673.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39394,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,WELLMED,WELLMED, 1167.20,,OUTPAT REV HCPCS COMBO 1, 1428.39,OTHER, 432.18, 2660.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39395,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,WELLMED,WELLMED, 1167.20,,OUTPAT REV HCPCS COMBO 1, 1428.39,OTHER, 432.18, 2660.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39396,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39397,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39398,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39399,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,WELLMED,WELLMED, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39400,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,WELLMED,WELLMED, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39401,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,WELLMED,WELLMED, 580.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39402,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39403,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39404,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39405,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,WELLMED,WELLMED, 597.27,,OUTPAT REV HCPCS COMBO 1, 796.22,OTHER, 495.38, 1361.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39406,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,WELLMED,WELLMED, 597.27,,OUTPAT REV HCPCS COMBO 1, 796.22,OTHER, 495.38, 1361.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39407,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39408,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39409,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,WELLMED,WELLMED, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39410,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,WELLMED,WELLMED, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39411,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,WELLMED,WELLMED, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39412,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,WELLMED,WELLMED, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39413,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,WELLMED,WELLMED, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39414,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,WELLMED,WELLMED, 1272.34,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39415,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39416,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39417,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39418,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39419,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39420,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39421,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,WELLMED,WELLMED, 1556.76,,OUTPAT REV HCPCS COMBO 1, 1953.37,OTHER, 779.04, 3547.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39422,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,WELLMED,WELLMED, 1556.76,,OUTPAT REV HCPCS COMBO 1, 1953.37,OTHER, 779.04, 3547.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39423,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39424,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39425,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,WELLMED,WELLMED, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39426,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,WELLMED,WELLMED, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39427,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,WELLMED,WELLMED, 1356.11,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39428,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,WELLMED,WELLMED, 1356.11,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39429,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,WELLMED,WELLMED, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39430,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,WELLMED,WELLMED, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39431,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,WELLMED,WELLMED, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39432,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,WELLMED,WELLMED, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39433,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,WELLMED,WELLMED, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39434,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,WELLMED,WELLMED, 1356.10,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39435,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39436,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39437,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39438,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39439,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39440,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39441,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39442,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39443,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39444,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39445,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,WELLMED,WELLMED, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39446,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,WELLMED,WELLMED, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39447,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,WELLMED,WELLMED, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39448,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,WELLMED,WELLMED, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39449,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,WELLMED,WELLMED, 1979.25,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39450,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39451,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39452,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39453,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39454,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39455,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,WELLMED,WELLMED, 860.00,,OUTPAT REV HCPCS COMBO 1, 1227.35,OTHER, 786.90, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39456,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,WELLMED,WELLMED, 989.00,,OUTPAT REV HCPCS COMBO 1, 1323.48,OTHER, 786.90, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39457,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,WELLMED,WELLMED, 989.00,,OUTPAT REV HCPCS COMBO 1, 1474.10,OTHER, 989.00, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39458,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,WELLMED,WELLMED, 786.90,,OUTPAT REV HCPCS COMBO 1, 1227.35,OTHER, 786.90, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39459,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,WELLMED,WELLMED, 786.90,,OUTPAT REV HCPCS COMBO 1, 1323.48,OTHER, 786.90, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39460,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39461,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39462,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39463,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39464,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39465,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,WELLMED,WELLMED, 71.38,,OUTPAT REV HCPCS COMBO 1, 102.58,OTHER, 71.38, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39466,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,WELLMED,WELLMED, 71.38,,OUTPAT REV HCPCS COMBO 1, 102.58,OTHER, 71.38, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39467,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39468,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39469,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WELLMED,WELLMED, 36.98,,OUTPAT REV HCPCS COMBO 1, 83.13,OTHER, 36.98, 172.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39470,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39471,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,WELLMED,WELLMED, 254.96,,OUTPAT REV HCPCS COMBO 1, 322.43,OTHER, 138.19, 581.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39472,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,WELLMED,WELLMED, 254.96,,OUTPAT REV HCPCS COMBO 1, 322.43,OTHER, 138.19, 581.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39473,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39474,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39475,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,WELLMED,WELLMED, 1125.78,,OUTPAT REV HCPCS COMBO 1, 1346.03,OTHER, 283.82, 2565.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39476,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39477,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,WELLMED,WELLMED, 1269.20,,OUTPAT REV HCPCS COMBO 1, 1544.22,OTHER, 432.18, 2892.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39478,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39479,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,WELLMED,WELLMED, 1433.28,,OUTPAT REV HCPCS COMBO 1, 1743.20,OTHER, 485.27, 3266.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39480,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39481,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,WELLMED,WELLMED, 2571.41,,OUTPAT REV HCPCS COMBO 1, 3113.75,OTHER, 813.20, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39482,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39483,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,WELLMED,WELLMED, 1431.39,,OUTPAT REV HCPCS COMBO 1, 1743.46,OTHER, 495.38, 3262.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39484,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39485,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,WELLMED,WELLMED, 2239.96,,OUTPAT REV HCPCS COMBO 1, 2609.45,OTHER, 276.02, 5105.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39486,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,WELLMED,WELLMED, 2239.96,,OUTPAT REV HCPCS COMBO 1, 2609.45,OTHER, 276.02, 5105.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39487,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39488,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39489,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,WELLMED,WELLMED, 2571.41,,OUTPAT REV HCPCS COMBO 1, 3021.78,OTHER, 426.91, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39490,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,WELLMED,WELLMED, 2571.41,,OUTPAT REV HCPCS COMBO 1, 3021.78,OTHER, 426.91, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39491,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39492,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39493,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,WELLMED,WELLMED, 2881.09,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39494,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,WELLMED,WELLMED, 2881.09,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39495,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,WELLMED,WELLMED, 2881.09,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39496,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39497,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39498,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39499,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,WELLMED,WELLMED, 1381.27,,OUTPAT REV HCPCS COMBO 1, 1689.68,OTHER, 508.57, 3148.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39500,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,WELLMED,WELLMED, 1381.27,,OUTPAT REV HCPCS COMBO 1, 1689.68,OTHER, 508.57, 3148.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39501,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39502,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39503,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,WELLMED,WELLMED, 1454.34,,OUTPAT REV HCPCS COMBO 1, 1837.06,OTHER, 779.04, 3314.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39504,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39505,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,WELLMED,WELLMED, 1075.00,,OUTPAT REV HCPCS COMBO 1, 2098.35,OTHER, 1075.00, 3967.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39506,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,WELLMED,WELLMED, 1740.64,,OUTPAT REV HCPCS COMBO 1, 2098.35,OTHER, 1075.00, 3967.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39507,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39508,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39509,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39510,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,WELLMED,WELLMED, 300.14,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39511,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,WELLMED,WELLMED, 300.14,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39512,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,WELLMED,WELLMED, 300.14,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39513,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39514,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39515,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,WELLMED,WELLMED, 472.37,,OUTPAT REV HCPCS COMBO 1, 704.06,OTHER, 472.37, 1076.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39516,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39517,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,WELLMED,WELLMED, 166.15,,OUTPAT REV HCPCS COMBO 1, 248.14,OTHER, 166.15, 378.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39518,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39519,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,WELLMED,WELLMED, 326.19,,OUTPAT REV HCPCS COMBO 1, 429.88,OTHER, 249.71, 743.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39520,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39521,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,WELLMED,WELLMED, 1213.11,,OUTPAT REV HCPCS COMBO 1, 1495.57,OTHER, 495.38, 2764.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39522,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,WELLMED,WELLMED, 1213.11,,OUTPAT REV HCPCS COMBO 1, 1495.57,OTHER, 495.38, 2764.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39523,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39524,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39525,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,WELLMED,WELLMED, 150.50,,OUTPAT REV HCPCS COMBO 1, 224.32,OTHER, 150.50, 343.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39526,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39527,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,WELLMED,WELLMED, 309.81,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39528,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,WELLMED,WELLMED, 309.81,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39529,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,WELLMED,WELLMED, 309.81,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39530,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39531,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39532,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39533,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,WELLMED,WELLMED, 233.31,,OUTPAT REV HCPCS COMBO 1, 286.59,OTHER, 90.89, 531.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39534,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39535,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,WELLMED,WELLMED, 219.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39536,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,WELLMED,WELLMED, 219.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39537,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,WELLMED,WELLMED, 219.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39538,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,WELLMED,WELLMED, 225.75,,OUTPAT REV HCPCS COMBO 1, 288.12,OTHER, 133.37, 514.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39539,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39540,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39541,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39542,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39543,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,WELLMED,WELLMED, 413.68,,OUTPAT REV HCPCS COMBO 1, 503.49,OTHER, 141.55, 942.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39544,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39545,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WELLMED,WELLMED, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39546,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WELLMED,WELLMED, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39547,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WELLMED,WELLMED, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39548,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WELLMED,WELLMED, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39549,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WELLMED,WELLMED, 377.80,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39550,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39551,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39552,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39553,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39554,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39555,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WELLMED,WELLMED, 377.80,,OUTPAT REV HCPCS COMBO 1, 468.07,OTHER, 163.97, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39556,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39557,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,WELLMED,WELLMED, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39558,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,WELLMED,WELLMED, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39559,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,WELLMED,WELLMED, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39560,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,WELLMED,WELLMED, 340.73,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39561,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,WELLMED,WELLMED, 335.33,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39562,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39563,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39564,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39565,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39566,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39567,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,WELLMED,WELLMED, 335.33,,OUTPAT REV HCPCS COMBO 1, 414.50,OTHER, 141.55, 764.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39568,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39569,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,WELLMED,WELLMED, 161.25,,OUTPAT REV HCPCS COMBO 1, 214.87,OTHER, 133.37, 367.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39570,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39571,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,WELLMED,WELLMED, 330.24,,OUTPAT REV HCPCS COMBO 1, 408.73,OTHER, 141.55, 752.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39572,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39573,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,WELLMED,WELLMED, 417.26,,OUTPAT REV HCPCS COMBO 1, 507.55,OTHER, 141.55, 950.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39574,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39575,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,WELLMED,WELLMED, 663.92,,OUTPAT REV HCPCS COMBO 1, 775.60,OTHER, 90.89, 1513.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39576,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39577,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,WELLMED,WELLMED, 227.90,,OUTPAT REV HCPCS COMBO 1, 290.56,OTHER, 133.37, 519.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39578,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39579,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,WELLMED,WELLMED, 339.97,,OUTPAT REV HCPCS COMBO 1, 419.77,OTHER, 141.55, 774.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39580,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39581,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,WELLMED,WELLMED, 385.59,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39582,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,WELLMED,WELLMED, 385.59,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39583,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,WELLMED,WELLMED, 385.59,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39584,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39585,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39586,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39587,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,WELLMED,WELLMED, 269.07,,OUTPAT REV HCPCS COMBO 1, 322.12,OTHER, 90.89, 613.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39588,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,WELLMED,WELLMED, 260.12,,OUTPAT REV HCPCS COMBO 1, 322.12,OTHER, 90.89, 613.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39589,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39590,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39591,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,WELLMED,WELLMED, 330.02,,OUTPAT REV HCPCS COMBO 1, 408.48,OTHER, 141.55, 752.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39592,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39593,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,WELLMED,WELLMED, 688.00,,OUTPAT REV HCPCS COMBO 1, 813.95,OTHER, 137.10, 1568.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39594,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,WELLMED,WELLMED, 435.01,,OUTPAT REV HCPCS COMBO 1, 526.64,OTHER, 137.10, 991.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39595,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,WELLMED,WELLMED, 435.01,,OUTPAT REV HCPCS COMBO 1, 526.64,OTHER, 137.10, 991.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39596,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39597,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39598,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39599,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,WELLMED,WELLMED, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39600,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,WELLMED,WELLMED, 236.50,,OUTPAT REV HCPCS COMBO 1, 300.33,OTHER, 133.37, 539.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39601,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,WELLMED,WELLMED, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39602,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,WELLMED,WELLMED, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39603,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,WELLMED,WELLMED, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39604,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,WELLMED,WELLMED, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39605,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,WELLMED,WELLMED, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39606,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,WELLMED,WELLMED, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39607,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,WELLMED,WELLMED, 154.35,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39608,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39609,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39610,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39611,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39612,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39613,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39614,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39615,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39616,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39617,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,WELLMED,WELLMED, 285.90,,OUTPAT REV HCPCS COMBO 1, 426.14,OTHER, 285.90, 651.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39618,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39619,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,WELLMED,WELLMED, 182.57,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39620,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,WELLMED,WELLMED, 182.57,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39621,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,WELLMED,WELLMED, 182.57,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39622,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39623,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39624,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39625,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39626,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,WELLMED,WELLMED, 125.13,,OUTPAT REV HCPCS COMBO 1, 186.51,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39627,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,WELLMED,WELLMED, 125.13,,OUTPAT REV HCPCS COMBO 1, 186.51,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39628,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,WELLMED,WELLMED, 61.06,,OUTPAT REV HCPCS COMBO 1, 91.01,OTHER, 61.06, 139.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39629,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,WELLMED,WELLMED, 21.15,,OUTPAT REV HCPCS COMBO 1, 78.82,OTHER, 21.15, 181.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39630,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,WELLMED,WELLMED, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39631,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,WELLMED,WELLMED, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39632,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,WELLMED,WELLMED, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39633,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,WELLMED,WELLMED, 125.13,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39634,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39635,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39636,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39637,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39638,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,WELLMED,WELLMED, 210.70,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39639,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,WELLMED,WELLMED, 175.87,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39640,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,WELLMED,WELLMED, 210.70,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39641,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39642,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39643,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,WELLMED,WELLMED, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39644,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,WELLMED,WELLMED, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39645,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,WELLMED,WELLMED, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39646,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,WELLMED,WELLMED, 81.44,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39647,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,WELLMED,WELLMED, 81.44,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39648,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,WELLMED,WELLMED, 81.44,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39649,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,WELLMED,WELLMED, 81.44,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39650,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39651,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39652,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39653,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39654,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39655,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39656,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39657,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,WELLMED,WELLMED, 73.53,,OUTPAT REV HCPCS COMBO 1, 116.40,OTHER, 73.53, 167.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39658,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39659,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,WELLMED,WELLMED, 315.98,,OUTPAT REV HCPCS COMBO 1, 414.07,OTHER, 232.03, 720.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39660,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,WELLMED,WELLMED, 84.28,,OUTPAT REV HCPCS COMBO 1, 158.67,OTHER, 84.28, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39661,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,WELLMED,WELLMED, 150.93,,OUTPAT REV HCPCS COMBO 1, 158.67,OTHER, 84.28, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39662,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39663,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39664,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,WELLMED,WELLMED, 127.28,,OUTPAT REV HCPCS COMBO 1, 154.63,OTHER, 42.36, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39665,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,WELLMED,WELLMED, 150.93,,OUTPAT REV HCPCS COMBO 1, 204.30,OTHER, 138.19, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39666,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39667,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,WELLMED,WELLMED, 549.04,,OUTPAT REV HCPCS COMBO 1, 660.83,OTHER, 156.82, 1251.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39668,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,WELLMED,WELLMED, 549.04,,OUTPAT REV HCPCS COMBO 1, 660.83,OTHER, 156.82, 1251.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39669,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39670,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39671,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,WELLMED,WELLMED, 426.80,,OUTPAT REV HCPCS COMBO 1, 533.81,OTHER, 206.35, 972.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39672,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,WELLMED,WELLMED, 426.80,,OUTPAT REV HCPCS COMBO 1, 533.81,OTHER, 206.35, 972.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39673,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39674,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39675,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,WELLMED,WELLMED, 600.24,,OUTPAT REV HCPCS COMBO 1, 757.92,OTHER, 320.35, 1367.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39676,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39677,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,WELLMED,WELLMED, 724.72,,OUTPAT REV HCPCS COMBO 1, 899.81,OTHER, 322.62, 1651.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39678,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39679,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,WELLMED,WELLMED, 847.10,,OUTPAT REV HCPCS COMBO 1, 1092.65,OTHER, 548.80, 1930.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39680,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39681,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,WELLMED,WELLMED, 672.15,,OUTPAT REV HCPCS COMBO 1, 864.03,OTHER, 423.08, 1531.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39682,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39683,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,WELLMED,WELLMED, 215.00,,OUTPAT REV HCPCS COMBO 1, 344.89,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39684,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39685,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,WELLMED,WELLMED, 645.00,,OUTPAT REV HCPCS COMBO 1, 830.31,OTHER, 410.92, 1470.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39686,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39687,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,WELLMED,WELLMED, 885.80,,OUTPAT REV HCPCS COMBO 1, 1103.77,OTHER, 410.92, 2018.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39688,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39689,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,WELLMED,WELLMED, 903.00,,OUTPAT REV HCPCS COMBO 1, 1111.16,OTHER, 359.95, 2058.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39690,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39691,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,WELLMED,WELLMED, 474.08,,OUTPAT REV HCPCS COMBO 1, 624.07,OTHER, 359.95, 1080.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39692,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39693,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,WELLMED,WELLMED, 516.57,,OUTPAT REV HCPCS COMBO 1, 672.34,OTHER, 360.01, 1177.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39694,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39695,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,WELLMED,WELLMED, 417.10,,OUTPAT REV HCPCS COMBO 1, 559.38,OTHER, 360.01, 950.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39696,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39697,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,WELLMED,WELLMED, 1005.92,,OUTPAT REV HCPCS COMBO 1, 1228.06,OTHER, 360.01, 2292.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39698,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39699,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,WELLMED,WELLMED, 1064.04,,OUTPAT REV HCPCS COMBO 1, 1294.05,OTHER, 360.01, 2425.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39700,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39701,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,WELLMED,WELLMED, 470.85,,OUTPAT REV HCPCS COMBO 1, 701.80,OTHER, 470.85, 1073.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39702,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39703,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,WELLMED,WELLMED, 775.51,,OUTPAT REV HCPCS COMBO 1, 1149.19,OTHER, 775.51, 1767.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39704,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,WELLMED,WELLMED, 775.51,,OUTPAT REV HCPCS COMBO 1, 1149.19,OTHER, 775.51, 1767.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39705,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39706,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39707,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,WELLMED,WELLMED, 1760.54,,OUTPAT REV HCPCS COMBO 1, 2267.81,OTHER, 1127.76, 4012.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39708,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39709,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,WELLMED,WELLMED, 624.40,,OUTPAT REV HCPCS COMBO 1, 815.01,OTHER, 444.92, 1423.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39710,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,WELLMED,WELLMED, 624.40,,OUTPAT REV HCPCS COMBO 1, 815.01,OTHER, 444.92, 1423.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39711,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39712,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39713,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,WELLMED,WELLMED, 500.41,,OUTPAT REV HCPCS COMBO 1, 635.79,OTHER, 283.54, 1140.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39714,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39715,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,WELLMED,WELLMED, 803.60,,OUTPAT REV HCPCS COMBO 1, 984.09,OTHER, 300.36, 1831.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39716,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39717,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,WELLMED,WELLMED, 831.76,,OUTPAT REV HCPCS COMBO 1, 1050.06,OTHER, 443.12, 1895.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39718,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39719,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,WELLMED,WELLMED, 447.20,,OUTPAT REV HCPCS COMBO 1, 684.67,OTHER, 447.20, 1019.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39720,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39721,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,WELLMED,WELLMED, 2048.52,,OUTPAT REV HCPCS COMBO 1, 2685.69,OTHER, 1509.32, 4668.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39722,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39723,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,WELLMED,WELLMED, 2121.62,,OUTPAT REV HCPCS COMBO 1, 2768.70,OTHER, 1509.32, 4835.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39724,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 39725,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,WELLMED,WELLMED, 26.05,,OUTPAT REV HCPCS COMBO 1, 34.30,OTHER, 19.78, 59.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39726,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,WELLMED,WELLMED, 26.05,,OUTPAT REV HCPCS COMBO 1, 32.49,OTHER, 12.18, 59.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39727,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,WELLMED,WELLMED, 267.46,,OUTPAT REV HCPCS COMBO 1, 398.65,OTHER, 267.46, 609.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39728,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,WELLMED,WELLMED, 60.14,,OUTPAT REV HCPCS COMBO 1, 70.69,OTHER, 10.09, 137.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39729,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,WELLMED,WELLMED, 104.38,,OUTPAT REV HCPCS COMBO 1, 122.16,OTHER, 15.20, 237.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39730,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,WELLMED,WELLMED, 81.90,,OUTPAT REV HCPCS COMBO 1, 97.60,OTHER, 19.28, 186.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39731,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,WELLMED,WELLMED, 81.90,,OUTPAT REV HCPCS COMBO 1, 97.60,OTHER, 19.28, 186.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39732,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,WELLMED,WELLMED, 70.95,,OUTPAT REV HCPCS COMBO 1, 83.55,OTHER, 12.50, 161.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39733,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,WELLMED,WELLMED, 70.95,,OUTPAT REV HCPCS COMBO 1, 83.55,OTHER, 12.50, 161.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39734,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,WELLMED,WELLMED, 122.86,,OUTPAT REV HCPCS COMBO 1, 155.85,OTHER, 68.59, 280.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39735,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,WELLMED,WELLMED, 67.08,,OUTPAT REV HCPCS COMBO 1, 78.98,OTHER, 11.76, 152.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39736,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,WELLMED,WELLMED, 56.33,,OUTPAT REV HCPCS COMBO 1, 69.30,OTHER, 22.37, 128.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39737,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,WELLMED,WELLMED, 192.21,,OUTPAT REV HCPCS COMBO 1, 229.30,OTHER, 46.28, 438.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39738,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,WELLMED,WELLMED, 75.79,,OUTPAT REV HCPCS COMBO 1, 88.95,OTHER, 20.98, 172.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39739,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,WELLMED,WELLMED, 72.07,,OUTPAT REV HCPCS COMBO 1, 88.95,OTHER, 20.98, 172.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39740,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,WELLMED,WELLMED, 43.00,,OUTPAT REV HCPCS COMBO 1, 53.39,OTHER, 19.13, 98.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39741,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,WELLMED,WELLMED, 43.00,,OUTPAT REV HCPCS COMBO 1, 53.39,OTHER, 19.13, 98.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39742,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,WELLMED,WELLMED, 66.51,,OUTPAT REV HCPCS COMBO 1, 80.17,OTHER, 19.50, 151.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39743,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,WELLMED,WELLMED, 41.55,,OUTPAT REV HCPCS COMBO 1, 54.61,OTHER, 31.20, 94.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39744,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,WELLMED,WELLMED, 66.47,,OUTPAT REV HCPCS COMBO 1, 80.03,OTHER, 19.08, 151.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39745,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,WELLMED,WELLMED, 65.72,,OUTPAT REV HCPCS COMBO 1, 79.17,OTHER, 19.08, 149.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39746,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,WELLMED,WELLMED, 54.32,,OUTPAT REV HCPCS COMBO 1, 63.95,OTHER, 9.52, 123.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39747,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,WELLMED,WELLMED, 20.21,,OUTPAT REV HCPCS COMBO 1, 28.28,OTHER, 20.21, 46.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39748,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,WELLMED,WELLMED, 69.69,,OUTPAT REV HCPCS COMBO 1, 83.69,OTHER, 19.08, 158.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39749,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,WELLMED,WELLMED, 42.46,,OUTPAT REV HCPCS COMBO 1, 53.47,OTHER, 22.03, 96.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39750,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,WELLMED,WELLMED, 66.28,,OUTPAT REV HCPCS COMBO 1, 79.81,OTHER, 19.08, 151.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39751,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,WELLMED,WELLMED, 35.17,,OUTPAT REV HCPCS COMBO 1, 44.64,OTHER, 19.78, 80.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39752,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,WELLMED,WELLMED, 124.34,,OUTPAT REV HCPCS COMBO 1, 145.91,OTHER, 19.78, 283.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39753,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,WELLMED,WELLMED, 52.76,,OUTPAT REV HCPCS COMBO 1, 64.76,OTHER, 20.36, 120.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39754,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,WELLMED,WELLMED, 103.25,,OUTPAT REV HCPCS COMBO 1, 121.34,OTHER, 17.16, 235.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39755,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,WELLMED,WELLMED, 70.55,,OUTPAT REV HCPCS COMBO 1, 84.76,OTHER, 19.50, 160.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39756,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,WELLMED,WELLMED, 111.79,,OUTPAT REV HCPCS COMBO 1, 134.69,OTHER, 32.53, 254.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39757,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,WELLMED,WELLMED, 74.42,,OUTPAT REV HCPCS COMBO 1, 90.91,OTHER, 26.84, 169.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39758,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,WELLMED,WELLMED, 81.85,,OUTPAT REV HCPCS COMBO 1, 56.90,OTHER, 10.75, 186.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39759,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,WELLMED,WELLMED, 10.75,,OUTPAT REV HCPCS COMBO 1, 56.90,OTHER, 10.75, 186.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39760,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,WELLMED,WELLMED, 17.20,,OUTPAT REV HCPCS COMBO 1, 23.85,OTHER, 17.20, 39.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39761,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,WELLMED,WELLMED, 17.20,,OUTPAT REV HCPCS COMBO 1, 23.85,OTHER, 17.20, 39.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39762,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,WELLMED,WELLMED, 112.61,,OUTPAT REV HCPCS COMBO 1, 178.46,OTHER, 112.61, 289.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39763,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,WELLMED,WELLMED, 126.85,,OUTPAT REV HCPCS COMBO 1, 178.46,OTHER, 112.61, 289.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39764,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,WELLMED,WELLMED, 72.67,,OUTPAT REV HCPCS COMBO 1, 108.31,OTHER, 72.67, 165.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39765,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,WELLMED,WELLMED, 64.50,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39766,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,WELLMED,WELLMED, 32.68,,OUTPAT REV HCPCS COMBO 1, 48.71,OTHER, 32.68, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39767,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,WELLMED,WELLMED, 120.73,,OUTPAT REV HCPCS COMBO 1, 179.95,OTHER, 120.73, 275.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39768,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,WELLMED,WELLMED, 76.91,,OUTPAT REV HCPCS COMBO 1, 114.63,OTHER, 76.91, 175.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39769,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,WELLMED,WELLMED, 17.56,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39770,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,WELLMED,WELLMED, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39771,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,WELLMED,WELLMED, 17.56,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39772,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,WELLMED,WELLMED, 17.56,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39773,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,WELLMED,WELLMED, 60.63,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39774,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,WELLMED,WELLMED, 45.53,,OUTPAT REV HCPCS COMBO 1, 67.87,OTHER, 45.53, 103.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39775,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,WELLMED,WELLMED, 68.37,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39776,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,WELLMED,WELLMED, 68.37,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39777,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,WELLMED,WELLMED, 68.37,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39778,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,WELLMED,WELLMED, 58.05,,OUTPAT REV HCPCS COMBO 1, 86.52,OTHER, 58.05, 132.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39779,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,WELLMED,WELLMED, 36.98,,OUTPAT REV HCPCS COMBO 1, 120.81,OTHER, 36.98, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39780,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,WELLMED,WELLMED, 125.13,,OUTPAT REV HCPCS COMBO 1, 120.81,OTHER, 36.98, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39781,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,WELLMED,WELLMED, 29.76,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39782,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,WELLMED,WELLMED, 29.76,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39783,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,WELLMED,WELLMED, 29.76,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39784,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,WELLMED,WELLMED, 17.75,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39785,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,WELLMED,WELLMED, 17.75,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39786,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,WELLMED,WELLMED, 17.75,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39787,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,WELLMED,WELLMED, 5.59,,OUTPAT REV HCPCS COMBO 1, 7.12,OTHER, 3.24, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39788,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,WELLMED,WELLMED, 6.45,,OUTPAT REV HCPCS COMBO 1, 8.07,OTHER, 3.12, 14.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39789,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,WELLMED,WELLMED, 27.22,,OUTPAT REV HCPCS COMBO 1, 33.86,OTHER, 12.40, 62.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39790,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,WELLMED,WELLMED, 27.22,,OUTPAT REV HCPCS COMBO 1, 33.86,OTHER, 12.40, 62.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39791,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,WELLMED,WELLMED, 64.07,,OUTPAT REV HCPCS COMBO 1, 75.71,OTHER, 12.40, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39792,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,WELLMED,WELLMED, 64.07,,OUTPAT REV HCPCS COMBO 1, 75.71,OTHER, 12.40, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39793,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,WELLMED,WELLMED, 106.06,,OUTPAT REV HCPCS COMBO 1, 145.60,OTHER, 105.66, 241.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39794,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,WELLMED,WELLMED, 106.06,,OUTPAT REV HCPCS COMBO 1, 145.60,OTHER, 105.66, 241.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39795,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,WELLMED,WELLMED, 211.56,,OUTPAT REV HCPCS COMBO 1, 262.66,OTHER, 94.12, 482.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39796,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,WELLMED,WELLMED, 350.08,,OUTPAT REV HCPCS COMBO 1, 428.98,OTHER, 131.99, 797.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39797,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,WELLMED,WELLMED, 87.01,,OUTPAT REV HCPCS COMBO 1, 129.68,OTHER, 87.01, 198.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39798,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,WELLMED,WELLMED, 164.26,,OUTPAT REV HCPCS COMBO 1, 244.83,OTHER, 164.26, 374.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39799,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,WELLMED,WELLMED, 164.26,,OUTPAT REV HCPCS COMBO 1, 244.83,OTHER, 164.26, 374.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39800,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,WELLMED,WELLMED, 45.44,,OUTPAT REV HCPCS COMBO 1, 53.15,OTHER, 6.50, 103.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39801,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,WELLMED,WELLMED, 31.79,,OUTPAT REV HCPCS COMBO 1, 38.90,OTHER, 11.76, 72.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39802,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,WELLMED,WELLMED, 117.64,,OUTPAT REV HCPCS COMBO 1, 146.83,OTHER, 55.61, 268.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39803,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,WELLMED,WELLMED, 16.23,,OUTPAT REV HCPCS COMBO 1, 20.13,OTHER, 7.13, 37.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39804,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,WELLMED,WELLMED, 16.23,,OUTPAT REV HCPCS COMBO 1, 20.13,OTHER, 7.13, 37.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39805,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,WELLMED,WELLMED, 23.11,,OUTPAT REV HCPCS COMBO 1, 28.92,OTHER, 11.21, 52.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39806,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,WELLMED,WELLMED, 23.11,,OUTPAT REV HCPCS COMBO 1, 28.92,OTHER, 11.21, 52.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39807,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,WELLMED,WELLMED, 51.60,,OUTPAT REV HCPCS COMBO 1, 60.58,OTHER, 8.33, 117.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39808,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,WELLMED,WELLMED, 51.60,,OUTPAT REV HCPCS COMBO 1, 60.58,OTHER, 8.33, 117.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39809,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,WELLMED,WELLMED, 41.87,,OUTPAT REV HCPCS COMBO 1, 50.88,OTHER, 13.98, 95.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39810,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,WELLMED,WELLMED, 58.52,,OUTPAT REV HCPCS COMBO 1, 71.06,OTHER, 19.36, 133.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39811,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,WELLMED,WELLMED, 92.38,,OUTPAT REV HCPCS COMBO 1, 109.86,OTHER, 20.82, 210.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39812,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,WELLMED,WELLMED, 65.53,,OUTPAT REV HCPCS COMBO 1, 80.16,OTHER, 24.14, 149.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39813,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,WELLMED,WELLMED, 65.53,,OUTPAT REV HCPCS COMBO 1, 80.16,OTHER, 24.14, 149.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39814,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,WELLMED,WELLMED, 51.17,,OUTPAT REV HCPCS COMBO 1, 63.10,OTHER, 20.98, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39815,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,WELLMED,WELLMED, 51.17,,OUTPAT REV HCPCS COMBO 1, 63.10,OTHER, 20.98, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39816,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,WELLMED,WELLMED, 42.77,,OUTPAT REV HCPCS COMBO 1, 50.79,OTHER, 9.34, 97.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39817,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,WELLMED,WELLMED, 42.77,,OUTPAT REV HCPCS COMBO 1, 50.79,OTHER, 9.34, 97.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39818,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,WELLMED,WELLMED, 79.55,,OUTPAT REV HCPCS COMBO 1, 100.38,OTHER, 42.16, 181.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39819,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,WELLMED,WELLMED, 97.65,,OUTPAT REV HCPCS COMBO 1, 121.92,OTHER, 46.34, 222.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39820,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,WELLMED,WELLMED, 37.84,,OUTPAT REV HCPCS COMBO 1, 50.20,OTHER, 30.37, 86.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39821,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,WELLMED,WELLMED, 96.70,,OUTPAT REV HCPCS COMBO 1, 116.31,OTHER, 27.31, 220.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39822,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,WELLMED,WELLMED, 40.85,,OUTPAT REV HCPCS COMBO 1, 49.78,OTHER, 14.24, 93.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39823,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,WELLMED,WELLMED, 50.98,,OUTPAT REV HCPCS COMBO 1, 63.44,OTHER, 23.30, 116.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39824,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,WELLMED,WELLMED, 30.50,,OUTPAT REV HCPCS COMBO 1, 36.36,OTHER, 7.22, 69.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39825,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,WELLMED,WELLMED, 30.50,,OUTPAT REV HCPCS COMBO 1, 36.36,OTHER, 7.22, 69.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39826,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,WELLMED,WELLMED, 27.61,,OUTPAT REV HCPCS COMBO 1, 33.07,OTHER, 7.22, 62.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39827,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,WELLMED,WELLMED, 15.70,,OUTPAT REV HCPCS COMBO 1, 19.33,OTHER, 6.31, 35.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39828,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,WELLMED,WELLMED, 28.02,,OUTPAT REV HCPCS COMBO 1, 33.34,OTHER, 6.38, 63.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39829,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED, 45.15,,OUTPAT REV HCPCS COMBO 1, 56.73,OTHER, 22.92, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39830,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,WELLMED,WELLMED, 100.38,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39831,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,WELLMED,WELLMED, 107.07,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39832,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,WELLMED,WELLMED, 100.38,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39833,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,WELLMED,WELLMED, 100.80,,OUTPAT REV HCPCS COMBO 1, 123.66,OTHER, 38.58, 229.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39834,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,WELLMED,WELLMED, 28.45,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39835,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,WELLMED,WELLMED, 28.45,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39836,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,WELLMED,WELLMED, 28.45,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39837,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,WELLMED,WELLMED, 56.84,,OUTPAT REV HCPCS COMBO 1, 69.24,OTHER, 19.70, 129.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39838,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,WELLMED,WELLMED, 42.18,,OUTPAT REV HCPCS COMBO 1, 49.97,OTHER, 8.69, 96.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39839,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,WELLMED,WELLMED, 35.26,,OUTPAT REV HCPCS COMBO 1, 44.47,OTHER, 18.58, 80.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39840,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,WELLMED,WELLMED, 53.64,,OUTPAT REV HCPCS COMBO 1, 65.14,OTHER, 17.74, 122.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39841,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,WELLMED,WELLMED, 71.10,,OUTPAT REV HCPCS COMBO 1, 87.25,OTHER, 27.30, 162.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39842,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,WELLMED,WELLMED, 71.10,,OUTPAT REV HCPCS COMBO 1, 87.25,OTHER, 27.30, 162.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39843,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,WELLMED,WELLMED, 46.87,,OUTPAT REV HCPCS COMBO 1, 59.01,OTHER, 24.29, 106.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39844,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,WELLMED,WELLMED, 104.53,,OUTPAT REV HCPCS COMBO 1, 127.93,OTHER, 36.36, 240.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39845,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,WELLMED,WELLMED, 105.53,,OUTPAT REV HCPCS COMBO 1, 127.93,OTHER, 36.36, 240.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39846,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,WELLMED,WELLMED, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.46,OTHER, 15.47, 105.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39847,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,WELLMED,WELLMED, 10.32,,OUTPAT REV HCPCS COMBO 1, 13.69,OTHER, 8.28, 23.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39848,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,WELLMED,WELLMED, 61.16,,OUTPAT REV HCPCS COMBO 1, 73.71,OTHER, 17.87, 139.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39849,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,WELLMED,WELLMED, 72.21,,OUTPAT REV HCPCS COMBO 1, 87.73,OTHER, 24.06, 164.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39850,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,WELLMED,WELLMED, 72.21,,OUTPAT REV HCPCS COMBO 1, 87.73,OTHER, 24.06, 164.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39851,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,WELLMED,WELLMED, 53.47,,OUTPAT REV HCPCS COMBO 1, 66.31,OTHER, 23.47, 121.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39852,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,WELLMED,WELLMED, 53.47,,OUTPAT REV HCPCS COMBO 1, 66.31,OTHER, 23.47, 121.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39853,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,WELLMED,WELLMED, 160.20,,OUTPAT REV HCPCS COMBO 1, 190.19,OTHER, 34.69, 365.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39854,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,WELLMED,WELLMED, 181.18,,OUTPAT REV HCPCS COMBO 1, 214.01,OTHER, 34.69, 412.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39855,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,WELLMED,WELLMED, 39.85,,OUTPAT REV HCPCS COMBO 1, 47.49,OTHER, 9.37, 90.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39856,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,WELLMED,WELLMED, 39.85,,OUTPAT REV HCPCS COMBO 1, 47.49,OTHER, 9.37, 90.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39857,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,WELLMED,WELLMED, 32.68,,OUTPAT REV HCPCS COMBO 1, 41.70,OTHER, 19.28, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39858,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,WELLMED,WELLMED, 49.11,,OUTPAT REV HCPCS COMBO 1, 59.73,OTHER, 16.63, 111.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39859,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,WELLMED,WELLMED, 26.30,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39860,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,WELLMED,WELLMED, 26.30,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39861,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,WELLMED,WELLMED, 26.30,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39862,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,WELLMED,WELLMED, 32.88,,OUTPAT REV HCPCS COMBO 1, 39.11,OTHER, 7.46, 74.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39863,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,WELLMED,WELLMED, 32.88,,OUTPAT REV HCPCS COMBO 1, 39.11,OTHER, 7.46, 74.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39864,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,WELLMED,WELLMED, 79.45,,OUTPAT REV HCPCS COMBO 1, 93.47,OTHER, 13.62, 181.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39865,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,WELLMED,WELLMED, 79.45,,OUTPAT REV HCPCS COMBO 1, 93.47,OTHER, 13.62, 181.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39866,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,WELLMED,WELLMED, 36.12,,OUTPAT REV HCPCS COMBO 1, 45.06,OTHER, 16.97, 82.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39867,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,WELLMED,WELLMED, 65.16,,OUTPAT REV HCPCS COMBO 1, 76.21,OTHER, 9.31, 148.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39868,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,WELLMED,WELLMED, 59.05,,OUTPAT REV HCPCS COMBO 1, 72.23,OTHER, 21.72, 134.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39869,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,WELLMED,WELLMED, 59.05,,OUTPAT REV HCPCS COMBO 1, 72.23,OTHER, 21.72, 134.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39870,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,WELLMED,WELLMED, 60.77,,OUTPAT REV HCPCS COMBO 1, 75.36,OTHER, 26.66, 138.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39871,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,WELLMED,WELLMED, 60.77,,OUTPAT REV HCPCS COMBO 1, 75.36,OTHER, 26.66, 138.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39872,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,WELLMED,WELLMED, 104.58,,OUTPAT REV HCPCS COMBO 1, 127.42,OTHER, 36.38, 238.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39873,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,WELLMED,WELLMED, 104.58,,OUTPAT REV HCPCS COMBO 1, 127.42,OTHER, 36.38, 238.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39874,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,WELLMED,WELLMED, 76.99,,OUTPAT REV HCPCS COMBO 1, 93.87,OTHER, 27.06, 175.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39875,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,WELLMED,WELLMED, 110.87,,OUTPAT REV HCPCS COMBO 1, 135.49,OTHER, 40.24, 252.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39876,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,WELLMED,WELLMED, 110.87,,OUTPAT REV HCPCS COMBO 1, 135.49,OTHER, 40.24, 252.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39877,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,WELLMED,WELLMED, 64.07,,OUTPAT REV HCPCS COMBO 1, 83.83,OTHER, 46.51, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39878,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,WELLMED,WELLMED, 57.62,,OUTPAT REV HCPCS COMBO 1, 73.72,OTHER, 34.82, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39879,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,WELLMED,WELLMED, 58.91,,OUTPAT REV HCPCS COMBO 1, 75.45,OTHER, 35.93, 134.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39880,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,WELLMED,WELLMED, 100.08,,OUTPAT REV HCPCS COMBO 1, 121.64,OTHER, 33.53, 228.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39881,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,WELLMED,WELLMED, 59.37,,OUTPAT REV HCPCS COMBO 1, 69.17,OTHER, 7.34, 135.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39882,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,WELLMED,WELLMED, 104.71,,OUTPAT REV HCPCS COMBO 1, 124.67,OTHER, 24.19, 238.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39883,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,WELLMED,WELLMED, 63.21,,OUTPAT REV HCPCS COMBO 1, 76.46,OTHER, 19.63, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39884,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,WELLMED,WELLMED, 58.51,,OUTPAT REV HCPCS COMBO 1, 71.48,OTHER, 21.17, 133.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39885,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,WELLMED,WELLMED, 182.22,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39886,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,WELLMED,WELLMED, 66.65,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39887,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,WELLMED,WELLMED, 45.48,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39888,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,WELLMED,WELLMED, 45.48,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39889,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,WELLMED,WELLMED, 45.48,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39890,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,WELLMED,WELLMED, 52.23,,OUTPAT REV HCPCS COMBO 1, 64.96,OTHER, 23.70, 119.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39891,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,WELLMED,WELLMED, 28.38,,OUTPAT REV HCPCS COMBO 1, 34.98,OTHER, 11.54, 64.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39892,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,WELLMED,WELLMED, 171.35,,OUTPAT REV HCPCS COMBO 1, 203.52,OTHER, 37.54, 390.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39893,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,WELLMED,WELLMED, 49.02,,OUTPAT REV HCPCS COMBO 1, 61.71,OTHER, 25.39, 111.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39894,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,WELLMED,WELLMED, 21.39,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39895,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,WELLMED,WELLMED, 21.39,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39896,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,WELLMED,WELLMED, 21.39,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39897,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,WELLMED,WELLMED, 23.75,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39898,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,WELLMED,WELLMED, 23.75,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39899,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,WELLMED,WELLMED, 23.75,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39900,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,WELLMED,WELLMED, 11.27,,OUTPAT REV HCPCS COMBO 1, 14.14,OTHER, 5.66, 25.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39901,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,WELLMED,WELLMED, 55.33,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 6.84, 126.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39902,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,WELLMED,WELLMED, 55.33,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 6.84, 126.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39903,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,WELLMED,WELLMED, 48.07,,OUTPAT REV HCPCS COMBO 1, 57.91,OTHER, 13.97, 109.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39904,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,WELLMED,WELLMED, 30.89,,OUTPAT REV HCPCS COMBO 1, 37.55,OTHER, 10.37, 70.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39905,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,WELLMED,WELLMED, 77.81,,OUTPAT REV HCPCS COMBO 1, 94.73,OTHER, 26.76, 177.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39906,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,WELLMED,WELLMED, 77.81,,OUTPAT REV HCPCS COMBO 1, 94.73,OTHER, 26.76, 177.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39907,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,WELLMED,WELLMED, 77.64,,OUTPAT REV HCPCS COMBO 1, 94.52,OTHER, 26.66, 176.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39908,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,WELLMED,WELLMED, 77.64,,OUTPAT REV HCPCS COMBO 1, 94.52,OTHER, 26.66, 176.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39909,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,WELLMED,WELLMED, 55.24,,OUTPAT REV HCPCS COMBO 1, 67.05,OTHER, 18.12, 125.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39910,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,WELLMED,WELLMED, 59.34,,OUTPAT REV HCPCS COMBO 1, 74.92,OTHER, 31.62, 135.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39911,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,WELLMED,WELLMED, 39.60,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39912,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,WELLMED,WELLMED, 39.60,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39913,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,WELLMED,WELLMED, 39.60,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39914,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,WELLMED,WELLMED, 82.50,,OUTPAT REV HCPCS COMBO 1, 99.83,OTHER, 25.80, 188.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39915,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,WELLMED,WELLMED, 129.43,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39916,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,WELLMED,WELLMED, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39917,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,WELLMED,WELLMED, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39918,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,WELLMED,WELLMED, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39919,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,WELLMED,WELLMED, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39920,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,WELLMED,WELLMED, 114.11,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39921,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,WELLMED,WELLMED, 127.54,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39922,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,WELLMED,WELLMED, 77.00,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39923,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,WELLMED,WELLMED, 118.72,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39924,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,WELLMED,WELLMED, 18.49,,OUTPAT REV HCPCS COMBO 1, 25.93,OTHER, 18.49, 42.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39925,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,WELLMED,WELLMED, 57.34,,OUTPAT REV HCPCS COMBO 1, 69.04,OTHER, 16.46, 130.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39926,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,WELLMED,WELLMED, 36.69,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39927,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,WELLMED,WELLMED, 36.69,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39928,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,WELLMED,WELLMED, 36.69,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39929,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,WELLMED,WELLMED, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39930,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,WELLMED,WELLMED, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39931,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,WELLMED,WELLMED, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39932,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,WELLMED,WELLMED, 44.89,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39933,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,WELLMED,WELLMED, 58.18,,OUTPAT REV HCPCS COMBO 1, 70.04,OTHER, 16.66, 132.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39934,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,WELLMED,WELLMED, 37.18,,OUTPAT REV HCPCS COMBO 1, 51.00,OTHER, 8.70, 111.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39935,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,WELLMED,WELLMED, 48.99,,OUTPAT REV HCPCS COMBO 1, 51.00,OTHER, 8.70, 111.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39936,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,WELLMED,WELLMED, 71.38,,OUTPAT REV HCPCS COMBO 1, 85.45,OTHER, 18.42, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39937,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,WELLMED,WELLMED, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.77,OTHER, 28.37, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39938,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,WELLMED,WELLMED, 44.57,,OUTPAT REV HCPCS COMBO 1, 54.77,OTHER, 17.44, 101.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39939,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,WELLMED,WELLMED, 44.57,,OUTPAT REV HCPCS COMBO 1, 54.77,OTHER, 17.44, 101.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39940,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,WELLMED,WELLMED, 51.17,,OUTPAT REV HCPCS COMBO 1, 60.48,OTHER, 9.92, 116.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39941,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,WELLMED,WELLMED, 51.17,,OUTPAT REV HCPCS COMBO 1, 60.48,OTHER, 9.92, 116.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39942,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,WELLMED,WELLMED, 117.27,,OUTPAT REV HCPCS COMBO 1, 149.05,OTHER, 66.68, 267.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39943,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,WELLMED,WELLMED, 27.95,,OUTPAT REV HCPCS COMBO 1, 43.46,OTHER, 27.95, 63.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39944,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,WELLMED,WELLMED, 34.70,,OUTPAT REV HCPCS COMBO 1, 43.01,OTHER, 15.12, 79.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39945,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,WELLMED,WELLMED, 34.70,,OUTPAT REV HCPCS COMBO 1, 43.01,OTHER, 15.12, 79.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39946,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,WELLMED,WELLMED, 33.76,,OUTPAT REV HCPCS COMBO 1, 40.64,OTHER, 9.65, 76.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39947,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,WELLMED,WELLMED, 172.39,,OUTPAT REV HCPCS COMBO 1, 204.04,OTHER, 34.72, 392.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39948,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,WELLMED,WELLMED, 45.72,,OUTPAT REV HCPCS COMBO 1, 57.49,OTHER, 23.41, 104.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39949,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,WELLMED,WELLMED, 135.39,,OUTPAT REV HCPCS COMBO 1, 159.56,OTHER, 24.40, 308.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39950,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,WELLMED,WELLMED, 135.39,,OUTPAT REV HCPCS COMBO 1, 159.56,OTHER, 24.40, 308.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39951,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,WELLMED,WELLMED, 71.67,,OUTPAT REV HCPCS COMBO 1, 74.79,OTHER, 18.60, 163.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39952,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,WELLMED,WELLMED, 52.25,,OUTPAT REV HCPCS COMBO 1, 74.79,OTHER, 18.60, 163.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39953,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,WELLMED,WELLMED, 94.17,,OUTPAT REV HCPCS COMBO 1, 120.40,OTHER, 56.53, 214.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39954,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,WELLMED,WELLMED, 94.17,,OUTPAT REV HCPCS COMBO 1, 120.40,OTHER, 56.53, 214.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39955,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,WELLMED,WELLMED, 91.30,,OUTPAT REV HCPCS COMBO 1, 110.95,OTHER, 30.54, 208.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39956,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,WELLMED,WELLMED, 45.70,,OUTPAT REV HCPCS COMBO 1, 54.17,OTHER, 9.52, 104.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39957,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,WELLMED,WELLMED, 37.08,,OUTPAT REV HCPCS COMBO 1, 44.45,OTHER, 9.82, 84.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39958,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,WELLMED,WELLMED, 37.08,,OUTPAT REV HCPCS COMBO 1, 44.45,OTHER, 9.82, 84.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39959,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,WELLMED,WELLMED, 71.50,,OUTPAT REV HCPCS COMBO 1, 86.15,OTHER, 20.81, 162.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39960,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,WELLMED,WELLMED, 116.98,,OUTPAT REV HCPCS COMBO 1, 147.00,OTHER, 59.45, 266.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39961,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,WELLMED,WELLMED, 116.98,,OUTPAT REV HCPCS COMBO 1, 147.00,OTHER, 59.45, 266.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39962,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,WELLMED,WELLMED, 32.68,,OUTPAT REV HCPCS COMBO 1, 43.75,OTHER, 27.89, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39963,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,WELLMED,WELLMED, 158.40,,OUTPAT REV HCPCS COMBO 1, 186.61,OTHER, 28.27, 361.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39964,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,WELLMED,WELLMED, 36.98,,OUTPAT REV HCPCS COMBO 1, 45.87,OTHER, 7.46, 92.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39965,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,WELLMED,WELLMED, 40.68,,OUTPAT REV HCPCS COMBO 1, 45.87,OTHER, 7.46, 92.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39966,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,WELLMED,WELLMED, 29.56,,OUTPAT REV HCPCS COMBO 1, 35.19,OTHER, 6.83, 67.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39967,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,WELLMED,WELLMED, 29.56,,OUTPAT REV HCPCS COMBO 1, 35.19,OTHER, 6.83, 67.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39968,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,WELLMED,WELLMED, 23.99,,OUTPAT REV HCPCS COMBO 1, 28.87,OTHER, 6.85, 54.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39969,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,WELLMED,WELLMED, 10.75,,OUTPAT REV HCPCS COMBO 1, 13.83,OTHER, 6.82, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39970,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,WELLMED,WELLMED, 35.72,,OUTPAT REV HCPCS COMBO 1, 45.56,OTHER, 21.01, 81.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39971,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,WELLMED,WELLMED, 75.35,,OUTPAT REV HCPCS COMBO 1, 92.72,OTHER, 30.04, 171.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39972,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,WELLMED,WELLMED, 75.35,,OUTPAT REV HCPCS COMBO 1, 92.72,OTHER, 30.04, 171.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39973,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,WELLMED,WELLMED, 82.30,,OUTPAT REV HCPCS COMBO 1, 102.79,OTHER, 39.19, 187.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39974,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,WELLMED,WELLMED, 79.71,,OUTPAT REV HCPCS COMBO 1, 97.17,OTHER, 27.91, 181.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39975,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,WELLMED,WELLMED, 71.08,,OUTPAT REV HCPCS COMBO 1, 90.21,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39976,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,WELLMED,WELLMED, 76.69,,OUTPAT REV HCPCS COMBO 1, 90.21,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39977,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,WELLMED,WELLMED, 76.69,,OUTPAT REV HCPCS COMBO 1, 93.39,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39978,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,WELLMED,WELLMED, 20.61,,OUTPAT REV HCPCS COMBO 1, 24.66,OTHER, 5.28, 46.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39979,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,WELLMED,WELLMED, 20.61,,OUTPAT REV HCPCS COMBO 1, 24.66,OTHER, 5.28, 46.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39980,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,WELLMED,WELLMED, 49.82,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39981,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,WELLMED,WELLMED, 49.82,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39982,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,WELLMED,WELLMED, 49.82,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39983,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,WELLMED,WELLMED, 35.17,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39984,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,WELLMED,WELLMED, 35.17,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39985,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,WELLMED,WELLMED, 36.73,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39986,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,WELLMED,WELLMED, 171.18,,OUTPAT REV HCPCS COMBO 1, 144.06,OTHER, 15.47, 390.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39987,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,WELLMED,WELLMED, 76.05,,OUTPAT REV HCPCS COMBO 1, 144.06,OTHER, 15.47, 390.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39988,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,WELLMED,WELLMED, 65.58,,OUTPAT REV HCPCS COMBO 1, 141.59,OTHER, 25.68, 394.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39989,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,WELLMED,WELLMED, 173.02,,OUTPAT REV HCPCS COMBO 1, 141.59,OTHER, 25.68, 394.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39990,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,WELLMED,WELLMED, 112.01,,OUTPAT REV HCPCS COMBO 1, 136.35,OTHER, 38.44, 255.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39991,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,WELLMED,WELLMED, 82.46,,OUTPAT REV HCPCS COMBO 1, 103.27,OTHER, 40.46, 187.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39992,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,WELLMED,WELLMED, 61.06,,OUTPAT REV HCPCS COMBO 1, 76.88,OTHER, 31.67, 139.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39993,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,WELLMED,WELLMED, 151.36,,OUTPAT REV HCPCS COMBO 1, 178.83,OTHER, 29.15, 344.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39994,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,WELLMED,WELLMED, 71.31,,OUTPAT REV HCPCS COMBO 1, 88.43,OTHER, 31.30, 162.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39995,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,WELLMED,WELLMED, 24.98,,OUTPAT REV HCPCS COMBO 1, 30.02,OTHER, 6.92, 56.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39996,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,WELLMED,WELLMED, 24.98,,OUTPAT REV HCPCS COMBO 1, 30.02,OTHER, 6.92, 56.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39997,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,WELLMED,WELLMED, 38.86,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39998,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,WELLMED,WELLMED, 38.86,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 39999,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,WELLMED,WELLMED, 7.98,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40000,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,WELLMED,WELLMED, 152.72,,OUTPAT REV HCPCS COMBO 1, 180.72,OTHER, 30.61, 348.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40001,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,WELLMED,WELLMED, 264.33,,OUTPAT REV HCPCS COMBO 1, 302.95,OTHER, 11.66, 602.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40002,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,WELLMED,WELLMED, 64.43,,OUTPAT REV HCPCS COMBO 1, 81.90,OTHER, 36.67, 146.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40003,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,WELLMED,WELLMED, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40004,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,WELLMED,WELLMED, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40005,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,WELLMED,WELLMED, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40006,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,WELLMED,WELLMED, 100.63,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40007,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,WELLMED,WELLMED, 70.02,,OUTPAT REV HCPCS COMBO 1, 86.80,OTHER, 30.58, 159.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40008,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,WELLMED,WELLMED, 70.02,,OUTPAT REV HCPCS COMBO 1, 86.80,OTHER, 30.58, 159.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40009,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,WELLMED,WELLMED, 89.69,,OUTPAT REV HCPCS COMBO 1, 107.35,OTHER, 23.12, 204.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40010,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,WELLMED,WELLMED, 89.69,,OUTPAT REV HCPCS COMBO 1, 107.35,OTHER, 23.12, 204.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40011,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,WELLMED,WELLMED, 44.84,,OUTPAT REV HCPCS COMBO 1, 53.27,OTHER, 9.89, 102.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40012,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,WELLMED,WELLMED, 44.84,,OUTPAT REV HCPCS COMBO 1, 53.27,OTHER, 9.89, 102.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40013,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,WELLMED,WELLMED, 64.16,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40014,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,WELLMED,WELLMED, 64.16,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40015,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,WELLMED,WELLMED, 64.16,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40016,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,WELLMED,WELLMED, 41.28,,OUTPAT REV HCPCS COMBO 1, 51.95,OTHER, 21.29, 94.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40017,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,WELLMED,WELLMED, 59.68,,OUTPAT REV HCPCS COMBO 1, 73.53,OTHER, 24.19, 136.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40018,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,WELLMED,WELLMED, 120.40,,OUTPAT REV HCPCS COMBO 1, 154.17,OTHER, 73.24, 274.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40019,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,WELLMED,WELLMED, 120.40,,OUTPAT REV HCPCS COMBO 1, 154.17,OTHER, 73.24, 274.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40020,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,WELLMED,WELLMED, 39.56,,OUTPAT REV HCPCS COMBO 1, 49.79,OTHER, 20.42, 90.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40021,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,WELLMED,WELLMED, 32.18,,OUTPAT REV HCPCS COMBO 1, 38.32,OTHER, 7.46, 73.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40022,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,WELLMED,WELLMED, 30.09,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, 7.63, 68.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40023,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,WELLMED,WELLMED, 47.67,,OUTPAT REV HCPCS COMBO 1, 58.51,OTHER, 18.37, 108.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40024,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,WELLMED,WELLMED, 32.73,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 8.27, 74.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40025,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,WELLMED,WELLMED, 65.64,,OUTPAT REV HCPCS COMBO 1, 79.41,OTHER, 20.42, 149.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40026,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,WELLMED,WELLMED, 65.64,,OUTPAT REV HCPCS COMBO 1, 79.41,OTHER, 20.42, 149.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40027,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,WELLMED,WELLMED, 64.36,,OUTPAT REV HCPCS COMBO 1, 78.90,OTHER, 24.40, 146.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40028,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,WELLMED,WELLMED, 64.36,,OUTPAT REV HCPCS COMBO 1, 78.90,OTHER, 24.40, 146.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40029,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,WELLMED,WELLMED, 106.98,,OUTPAT REV HCPCS COMBO 1, 126.89,OTHER, 22.69, 243.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40030,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,WELLMED,WELLMED, 69.32,,OUTPAT REV HCPCS COMBO 1, 82.99,OTHER, 17.95, 157.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40031,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,WELLMED,WELLMED, 69.32,,OUTPAT REV HCPCS COMBO 1, 82.99,OTHER, 17.95, 157.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40032,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,WELLMED,WELLMED, 33.26,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40033,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,WELLMED,WELLMED, 33.26,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40034,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,WELLMED,WELLMED, 33.26,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40035,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,WELLMED,WELLMED, 18.22,,OUTPAT REV HCPCS COMBO 1, 22.60,OTHER, 8.00, 41.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40036,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,WELLMED,WELLMED, 18.22,,OUTPAT REV HCPCS COMBO 1, 22.60,OTHER, 8.00, 41.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40037,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,WELLMED,WELLMED, 26.70,,OUTPAT REV HCPCS COMBO 1, 31.87,OTHER, 6.50, 60.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40038,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,WELLMED,WELLMED, 32.90,,OUTPAT REV HCPCS COMBO 1, 39.10,OTHER, 7.32, 74.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40039,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,WELLMED,WELLMED, 63.71,,OUTPAT REV HCPCS COMBO 1, 76.33,OTHER, 16.72, 145.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40040,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,WELLMED,WELLMED, 87.18,,OUTPAT REV HCPCS COMBO 1, 103.71,OTHER, 19.75, 198.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40041,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,WELLMED,WELLMED, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40042,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,WELLMED,WELLMED, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40043,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,WELLMED,WELLMED, 46.47,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40044,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,WELLMED,WELLMED, 69.10,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 29.96, 157.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40045,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,WELLMED,WELLMED, 80.90,,OUTPAT REV HCPCS COMBO 1, 97.04,OTHER, 21.67, 184.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40046,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,WELLMED,WELLMED, 36.30,,OUTPAT REV HCPCS COMBO 1, 42.88,OTHER, 6.94, 82.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40047,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,WELLMED,WELLMED, 37.42,,OUTPAT REV HCPCS COMBO 1, 43.80,OTHER, 5.47, 85.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40048,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,WELLMED,WELLMED, 15.00,,OUTPAT REV HCPCS COMBO 1, 17.85,OTHER, 3.41, 34.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40049,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,WELLMED,WELLMED, 15.00,,OUTPAT REV HCPCS COMBO 1, 17.85,OTHER, 3.41, 34.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40050,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,WELLMED,WELLMED, 18.18,,OUTPAT REV HCPCS COMBO 1, 21.46,OTHER, 3.41, 41.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40051,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,WELLMED,WELLMED, 18.18,,OUTPAT REV HCPCS COMBO 1, 21.46,OTHER, 3.41, 41.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40052,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, 22.31,OTHER, .01, 84.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40053,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,WELLMED,WELLMED, 36.94,,OUTPAT REV HCPCS COMBO 1, 22.31,OTHER, .01, 84.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40054,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,WELLMED,WELLMED, 37.42,,OUTPAT REV HCPCS COMBO 1, 44.71,OTHER, 9.31, 85.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40055,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,WELLMED,WELLMED, 31.95,,OUTPAT REV HCPCS COMBO 1, 37.65,OTHER, 5.75, 72.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40056,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,WELLMED,WELLMED, 31.95,,OUTPAT REV HCPCS COMBO 1, 37.65,OTHER, 5.75, 72.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40057,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,WELLMED,WELLMED, 16.77,,OUTPAT REV HCPCS COMBO 1, 19.92,OTHER, 3.66, 38.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40058,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,WELLMED,WELLMED, 27.38,,OUTPAT REV HCPCS COMBO 1, 32.63,OTHER, 6.46, 62.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40059,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,WELLMED,WELLMED, 79.81,,OUTPAT REV HCPCS COMBO 1, 96.77,OTHER, 25.78, 181.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40060,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,WELLMED,WELLMED, 106.94,,OUTPAT REV HCPCS COMBO 1, 129.31,OTHER, 33.04, 243.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40061,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,WELLMED,WELLMED, 111.37,,OUTPAT REV HCPCS COMBO 1, 130.54,OTHER, 17.06, 253.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40062,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,WELLMED,WELLMED, 82.42,,OUTPAT REV HCPCS COMBO 1, 98.34,OTHER, 19.93, 187.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40063,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,WELLMED,WELLMED, 73.75,,OUTPAT REV HCPCS COMBO 1, 89.00,OTHER, 22.06, 168.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40064,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,WELLMED,WELLMED, 83.42,,OUTPAT REV HCPCS COMBO 1, 98.22,OTHER, 14.66, 190.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40065,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,WELLMED,WELLMED, 45.18,,OUTPAT REV HCPCS COMBO 1, 54.63,OTHER, 13.99, 102.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40066,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,WELLMED,WELLMED, 56.33,,OUTPAT REV HCPCS COMBO 1, 70.40,OTHER, 27.00, 128.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40067,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,WELLMED,WELLMED, 25.05,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40068,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,WELLMED,WELLMED, 24.89,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40069,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,WELLMED,WELLMED, 25.05,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40070,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,WELLMED,WELLMED, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40071,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,WELLMED,WELLMED, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40072,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,WELLMED,WELLMED, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40073,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,WELLMED,WELLMED, 11.18,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40074,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,WELLMED,WELLMED, 35.35,,OUTPAT REV HCPCS COMBO 1, 41.60,OTHER, 6.14, 80.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40075,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,WELLMED,WELLMED, 22.36,,OUTPAT REV HCPCS COMBO 1, 26.32,OTHER, 3.89, 50.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40076,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,WELLMED,WELLMED, 30.35,,OUTPAT REV HCPCS COMBO 1, 36.35,OTHER, 7.93, 69.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40077,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,WELLMED,WELLMED, 73.10,,OUTPAT REV HCPCS COMBO 1, 61.85,OTHER, 8.65, 166.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40078,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,WELLMED,WELLMED, 32.20,,OUTPAT REV HCPCS COMBO 1, 61.85,OTHER, 8.65, 166.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40079,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,WELLMED,WELLMED, 65.15,,OUTPAT REV HCPCS COMBO 1, 76.67,OTHER, 11.26, 148.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40080,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,WELLMED,WELLMED, 510.99,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40081,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,WELLMED,WELLMED, 138.89,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40082,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40083,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40084,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40085,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40086,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40087,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40088,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40089,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40090,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40091,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40092,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40093,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40094,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40095,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40096,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40097,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40098,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40099,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40100,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40101,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40102,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40103,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40104,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40105,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40106,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40107,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40108,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40109,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40110,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40111,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40112,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40113,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40114,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40115,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40116,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40117,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40118,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,WELLMED,WELLMED, 26.51,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40119,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40120,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40121,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40122,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40123,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,WELLMED,WELLMED, 13.80,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40124,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40125,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40126,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40127,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40128,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40129,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40130,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40131,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40132,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40133,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40134,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40135,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40136,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40137,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40138,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40139,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40140,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40141,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,WELLMED,WELLMED, 28.67,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40142,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,WELLMED,WELLMED, 161.14,,OUTPAT REV HCPCS COMBO 1, 189.29,OTHER, 26.45, 367.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40143,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,WELLMED,WELLMED, 98.39,,OUTPAT REV HCPCS COMBO 1, 115.17,OTHER, 14.46, 224.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40144,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,WELLMED,WELLMED, 57.32,,OUTPAT REV HCPCS COMBO 1, 91.70,OTHER, 17.41, 220.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40145,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,WELLMED,WELLMED, 96.87,,OUTPAT REV HCPCS COMBO 1, 91.70,OTHER, 17.41, 220.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40146,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,WELLMED,WELLMED, 39.70,,OUTPAT REV HCPCS COMBO 1, 48.91,OTHER, 16.07, 90.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40147,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,WELLMED,WELLMED, 37.63,,OUTPAT REV HCPCS COMBO 1, 45.23,OTHER, 10.51, 85.75,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40148,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,WELLMED,WELLMED, 13.48,,OUTPAT REV HCPCS COMBO 1, 17.08,OTHER, 7.46, 30.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40149,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,WELLMED,WELLMED, 13.48,,OUTPAT REV HCPCS COMBO 1, 17.08,OTHER, 7.46, 30.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40150,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,WELLMED,WELLMED, 48.27,,OUTPAT REV HCPCS COMBO 1, 59.25,OTHER, 18.65, 110.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40151,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,WELLMED,WELLMED, 75.07,,OUTPAT REV HCPCS COMBO 1, 93.98,OTHER, 36.65, 171.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40152,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,WELLMED,WELLMED, 113.28,,OUTPAT REV HCPCS COMBO 1, 137.37,OTHER, 36.65, 258.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40153,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,WELLMED,WELLMED, 64.24,,OUTPAT REV HCPCS COMBO 1, 78.46,OTHER, 23.14, 146.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40154,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,WELLMED,WELLMED, 56.01,,OUTPAT REV HCPCS COMBO 1, 67.64,OTHER, 17.28, 127.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40155,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,WELLMED,WELLMED, 55.87,,OUTPAT REV HCPCS COMBO 1, 67.64,OTHER, 17.28, 127.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40156,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,WELLMED,WELLMED, 62.28,,OUTPAT REV HCPCS COMBO 1, 77.69,OTHER, 29.26, 141.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40157,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,WELLMED,WELLMED, 51.73,,OUTPAT REV HCPCS COMBO 1, 63.19,OTHER, 18.65, 117.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40158,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,WELLMED,WELLMED, 51.66,,OUTPAT REV HCPCS COMBO 1, 65.88,OTHER, 19.79, 127.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40159,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,WELLMED,WELLMED, 56.08,,OUTPAT REV HCPCS COMBO 1, 65.88,OTHER, 19.79, 127.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40160,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,WELLMED,WELLMED, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40161,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,WELLMED,WELLMED, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40162,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,WELLMED,WELLMED, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40163,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,WELLMED,WELLMED, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40164,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,WELLMED,WELLMED, 60.90,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40165,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,WELLMED,WELLMED, 60.82,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40166,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,WELLMED,WELLMED, 51.97,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40167,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,WELLMED,WELLMED, 48.44,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40168,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,WELLMED,WELLMED, 68.37,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40169,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,WELLMED,WELLMED, 104.56,,OUTPAT REV HCPCS COMBO 1, 120.82,OTHER, 17.35, 238.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40170,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,WELLMED,WELLMED, 100.94,,OUTPAT REV HCPCS COMBO 1, 120.82,OTHER, 17.35, 238.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40171,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,WELLMED,WELLMED, 10.75,,OUTPAT REV HCPCS COMBO 1, 15.65,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40172,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,WELLMED,WELLMED, 64.09,,OUTPAT REV HCPCS COMBO 1, 80.94,OTHER, 29.96, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40173,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,WELLMED,WELLMED, 65.89,,OUTPAT REV HCPCS COMBO 1, 80.94,OTHER, 29.96, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40174,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,WELLMED,WELLMED, 68.68,,OUTPAT REV HCPCS COMBO 1, 85.12,OTHER, 29.96, 156.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40175,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,WELLMED,WELLMED, 84.81,,OUTPAT REV HCPCS COMBO 1, 103.45,OTHER, 29.96, 193.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40176,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,WELLMED,WELLMED, 58.18,,OUTPAT REV HCPCS COMBO 1, 125.05,OTHER, 24.97, 345.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40177,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,WELLMED,WELLMED, 151.58,,OUTPAT REV HCPCS COMBO 1, 125.05,OTHER, 24.97, 345.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40178,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,WELLMED,WELLMED, 42.94,,OUTPAT REV HCPCS COMBO 1, 50.54,OTHER, 7.46, 97.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40179,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,WELLMED,WELLMED, 71.51,,OUTPAT REV HCPCS COMBO 1, 88.87,OTHER, 32.17, 162.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40180,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,WELLMED,WELLMED, 52.03,,OUTPAT REV HCPCS COMBO 1, 66.43,OTHER, 30.83, 118.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40181,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,WELLMED,WELLMED, 46.01,,OUTPAT REV HCPCS COMBO 1, 57.43,OTHER, 21.72, 104.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40182,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,WELLMED,WELLMED, 226.29,,OUTPAT REV HCPCS COMBO 1, 265.06,OTHER, 33.95, 515.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40183,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,WELLMED,WELLMED, 63.21,,OUTPAT REV HCPCS COMBO 1, 80.97,OTHER, 38.57, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40184,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,WELLMED,WELLMED, 63.21,,OUTPAT REV HCPCS COMBO 1, 80.97,OTHER, 38.57, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40185,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,WELLMED,WELLMED, 87.08,,OUTPAT REV HCPCS COMBO 1, 111.82,OTHER, 54.34, 198.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40186,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,WELLMED,WELLMED, 141.00,,OUTPAT REV HCPCS COMBO 1, 176.22,OTHER, 67.64, 321.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40187,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,WELLMED,WELLMED, 69.45,,OUTPAT REV HCPCS COMBO 1, 88.05,OTHER, 38.57, 158.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40188,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,WELLMED,WELLMED, 69.45,,OUTPAT REV HCPCS COMBO 1, 88.05,OTHER, 38.57, 158.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40189,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,WELLMED,WELLMED, 57.62,,OUTPAT REV HCPCS COMBO 1, 68.73,OTHER, 13.84, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40190,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,WELLMED,WELLMED, 70.14,,OUTPAT REV HCPCS COMBO 1, 96.09,OTHER, 20.95, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40191,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,WELLMED,WELLMED, 90.30,,OUTPAT REV HCPCS COMBO 1, 96.09,OTHER, 20.95, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40192,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,WELLMED,WELLMED, 57.62,,OUTPAT REV HCPCS COMBO 1, 70.10,OTHER, 19.60, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40193,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,WELLMED,WELLMED, 39.55,,OUTPAT REV HCPCS COMBO 1, 46.86,OTHER, 8.16, 90.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40194,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,WELLMED,WELLMED, 39.55,,OUTPAT REV HCPCS COMBO 1, 46.86,OTHER, 8.16, 90.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40195,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,WELLMED,WELLMED, 150.07,,OUTPAT REV HCPCS COMBO 1, 191.67,OTHER, 89.24, 342.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40196,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,WELLMED,WELLMED, 8.04,,OUTPAT REV HCPCS COMBO 1, 12.31,OTHER, 8.04, 18.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40197,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,WELLMED,WELLMED, 15.01,,OUTPAT REV HCPCS COMBO 1, 18.56,OTHER, 6.34, 34.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40198,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,WELLMED,WELLMED, 27.34,,OUTPAT REV HCPCS COMBO 1, 36.21,OTHER, 21.67, 62.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40199,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,WELLMED,WELLMED, 45.58,,OUTPAT REV HCPCS COMBO 1, 55.25,OTHER, 14.66, 103.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40200,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,WELLMED,WELLMED, 31.44,,OUTPAT REV HCPCS COMBO 1, 40.13,OTHER, 18.58, 71.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40201,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,WELLMED,WELLMED, 54.61,,OUTPAT REV HCPCS COMBO 1, 66.54,OTHER, 19.00, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40202,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,WELLMED,WELLMED, 72.68,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40203,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,WELLMED,WELLMED, 72.68,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40204,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,WELLMED,WELLMED, 72.68,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40205,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,WELLMED,WELLMED, 19.93,,OUTPAT REV HCPCS COMBO 1, 26.75,OTHER, 17.29, 45.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40206,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,WELLMED,WELLMED, 41.68,,OUTPAT REV HCPCS COMBO 1, 91.08,OTHER, 16.51, 254.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40207,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,WELLMED,WELLMED, 111.80,,OUTPAT REV HCPCS COMBO 1, 91.08,OTHER, 16.51, 254.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40208,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,WELLMED,WELLMED, 40.42,,OUTPAT REV HCPCS COMBO 1, 50.83,OTHER, 20.72, 92.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40209,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,WELLMED,WELLMED, 46.87,,OUTPAT REV HCPCS COMBO 1, 59.00,OTHER, 24.26, 106.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40210,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,WELLMED,WELLMED, 52.14,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 22.02, 118.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40211,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,WELLMED,WELLMED, 46.92,,OUTPAT REV HCPCS COMBO 1, 59.50,OTHER, 26.12, 106.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40212,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,WELLMED,WELLMED, 46.92,,OUTPAT REV HCPCS COMBO 1, 59.50,OTHER, 26.12, 106.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40213,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,WELLMED,WELLMED, 78.68,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40214,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,WELLMED,WELLMED, 47.36,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40215,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,WELLMED,WELLMED, 47.36,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40216,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,WELLMED,WELLMED, 52.89,,OUTPAT REV HCPCS COMBO 1, 66.70,OTHER, 27.86, 120.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40217,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,WELLMED,WELLMED, 52.89,,OUTPAT REV HCPCS COMBO 1, 66.70,OTHER, 27.86, 120.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40218,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,WELLMED,WELLMED, 33.97,,OUTPAT REV HCPCS COMBO 1, 43.51,OTHER, 20.72, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40219,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,WELLMED,WELLMED, 38.00,,OUTPAT REV HCPCS COMBO 1, 47.68,OTHER, 19.00, 86.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40220,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,WELLMED,WELLMED, 45.58,,OUTPAT REV HCPCS COMBO 1, 58.39,OTHER, 27.86, 103.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40221,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,WELLMED,WELLMED, 64.05,,OUTPAT REV HCPCS COMBO 1, 77.47,OTHER, 19.86, 145.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40222,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,WELLMED,WELLMED, 50.90,,OUTPAT REV HCPCS COMBO 1, 62.50,OTHER, 19.74, 116.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40223,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,WELLMED,WELLMED, 37.53,,OUTPAT REV HCPCS COMBO 1, 46.75,OTHER, 17.35, 85.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40224,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,WELLMED,WELLMED, 32.68,,OUTPAT REV HCPCS COMBO 1, 41.14,OTHER, 16.94, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40225,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,WELLMED,WELLMED, 55.83,,OUTPAT REV HCPCS COMBO 1, 67.08,OTHER, 15.47, 127.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40226,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,WELLMED,WELLMED, 40.75,,OUTPAT REV HCPCS COMBO 1, 50.52,OTHER, 17.84, 92.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40227,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,WELLMED,WELLMED, 21.41,,OUTPAT REV HCPCS COMBO 1, 28.18,OTHER, 16.21, 48.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40228,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,WELLMED,WELLMED, 42.33,,OUTPAT REV HCPCS COMBO 1, 52.54,OTHER, 18.79, 96.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40229,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,WELLMED,WELLMED, 42.33,,OUTPAT REV HCPCS COMBO 1, 52.54,OTHER, 18.79, 96.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40230,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,WELLMED,WELLMED, 32.25,,OUTPAT REV HCPCS COMBO 1, 41.16,OTHER, 19.07, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40231,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,WELLMED,WELLMED, 36.26,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40232,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,WELLMED,WELLMED, 36.26,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40233,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,WELLMED,WELLMED, 36.26,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40234,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,WELLMED,WELLMED, 37.52,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40235,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,WELLMED,WELLMED, 38.81,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40236,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,WELLMED,WELLMED, 38.81,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40237,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,WELLMED,WELLMED, 39.49,,OUTPAT REV HCPCS COMBO 1, 49.38,OTHER, 19.07, 89.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40238,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,WELLMED,WELLMED, 66.65,,OUTPAT REV HCPCS COMBO 1, 80.11,OTHER, 18.55, 151.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40239,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,WELLMED,WELLMED, 66.65,,OUTPAT REV HCPCS COMBO 1, 80.11,OTHER, 18.55, 151.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40240,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,WELLMED,WELLMED, 314.67,,OUTPAT REV HCPCS COMBO 1, 361.76,OTHER, 18.55, 717.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40241,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,WELLMED,WELLMED, 138.03,,OUTPAT REV HCPCS COMBO 1, 161.64,OTHER, 20.54, 314.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40242,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,WELLMED,WELLMED, 120.30,,OUTPAT REV HCPCS COMBO 1, 158.63,OTHER, 92.44, 274.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40243,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,WELLMED,WELLMED, 120.30,,OUTPAT REV HCPCS COMBO 1, 158.63,OTHER, 92.44, 274.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40244,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,WELLMED,WELLMED, 65.75,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40245,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,WELLMED,WELLMED, 65.75,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40246,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,WELLMED,WELLMED, 65.75,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40247,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,WELLMED,WELLMED, 102.77,,OUTPAT REV HCPCS COMBO 1, 152.44,OTHER, 102.77, 234.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40248,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,WELLMED,WELLMED, 185.27,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40249,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,WELLMED,WELLMED, 185.27,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40250,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,WELLMED,WELLMED, 185.27,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40251,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,WELLMED,WELLMED, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40252,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,WELLMED,WELLMED, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40253,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,WELLMED,WELLMED, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40254,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,WELLMED,WELLMED, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40255,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,WELLMED,WELLMED, 70.37,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40256,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,WELLMED,WELLMED, 127.76,,OUTPAT REV HCPCS COMBO 1, 146.86,OTHER, 7.46, 291.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40257,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,WELLMED,WELLMED, 47.30,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40258,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,WELLMED,WELLMED, 47.30,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40259,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,WELLMED,WELLMED, 47.30,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40260,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,WELLMED,WELLMED, 39.16,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40261,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,WELLMED,WELLMED, 37.22,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40262,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,WELLMED,WELLMED, 39.16,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40263,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,WELLMED,WELLMED, 185.27,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40264,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,WELLMED,WELLMED, 185.27,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40265,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,WELLMED,WELLMED, 168.35,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40266,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,WELLMED,WELLMED, 59.99,,OUTPAT REV HCPCS COMBO 1, 70.78,OTHER, 11.16, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40267,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,WELLMED,WELLMED, 59.99,,OUTPAT REV HCPCS COMBO 1, 70.78,OTHER, 11.16, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40268,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,WELLMED,WELLMED, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40269,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,WELLMED,WELLMED, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40270,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,WELLMED,WELLMED, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40271,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,WELLMED,WELLMED, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40272,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,WELLMED,WELLMED, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40273,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,WELLMED,WELLMED, 255.51,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40274,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,WELLMED,WELLMED, 59.99,,OUTPAT REV HCPCS COMBO 1, 76.50,OTHER, 35.20, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40275,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,WELLMED,WELLMED, 112.23,,OUTPAT REV HCPCS COMBO 1, 149.18,OTHER, 91.25, 255.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40276,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,WELLMED,WELLMED, 68.57,,OUTPAT REV HCPCS COMBO 1, 81.41,OTHER, 14.86, 156.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40277,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,WELLMED,WELLMED, 68.57,,OUTPAT REV HCPCS COMBO 1, 81.41,OTHER, 14.86, 156.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40278,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,WELLMED,WELLMED, 24.24,,OUTPAT REV HCPCS COMBO 1, 30.76,OTHER, 13.60, 55.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40279,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,WELLMED,WELLMED, 61.36,,OUTPAT REV HCPCS COMBO 1, 72.64,OTHER, 12.41, 139.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40280,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,WELLMED,WELLMED, 61.36,,OUTPAT REV HCPCS COMBO 1, 72.64,OTHER, 12.41, 139.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40281,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,WELLMED,WELLMED, 66.06,,OUTPAT REV HCPCS COMBO 1, 78.26,OTHER, 13.63, 150.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40282,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,WELLMED,WELLMED, 66.06,,OUTPAT REV HCPCS COMBO 1, 78.26,OTHER, 13.63, 150.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40283,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,WELLMED,WELLMED, 67.12,,OUTPAT REV HCPCS COMBO 1, 78.99,OTHER, 11.64, 152.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40284,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,WELLMED,WELLMED, 38.75,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40285,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,WELLMED,WELLMED, 38.75,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40286,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,WELLMED,WELLMED, 38.75,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40287,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,WELLMED,WELLMED, 34.07,,OUTPAT REV HCPCS COMBO 1, 40.96,OTHER, 9.55, 77.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40288,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,WELLMED,WELLMED, 36.91,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40289,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,WELLMED,WELLMED, 36.91,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40290,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,WELLMED,WELLMED, 36.91,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40291,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,WELLMED,WELLMED, 70.00,,OUTPAT REV HCPCS COMBO 1, 82.26,OTHER, 11.65, 159.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40292,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,WELLMED,WELLMED, 70.00,,OUTPAT REV HCPCS COMBO 1, 82.26,OTHER, 11.65, 159.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40293,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,WELLMED,WELLMED, 63.28,,OUTPAT REV HCPCS COMBO 1, 74.74,OTHER, 12.11, 144.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40294,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,WELLMED,WELLMED, 76.88,,OUTPAT REV HCPCS COMBO 1, 91.00,OTHER, 15.55, 175.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40295,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,WELLMED,WELLMED, 57.47,,OUTPAT REV HCPCS COMBO 1, 68.31,OTHER, 12.82, 130.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40296,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,WELLMED,WELLMED, 14.19,,OUTPAT REV HCPCS COMBO 1, 17.74,OTHER, 6.84, 32.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40297,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,WELLMED,WELLMED, 17.99,,OUTPAT REV HCPCS COMBO 1, 22.99,OTHER, 10.78, 40.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40298,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,WELLMED,WELLMED, 24.94,,OUTPAT REV HCPCS COMBO 1, 29.95,OTHER, 6.84, 56.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40299,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,WELLMED,WELLMED, 34.74,,OUTPAT REV HCPCS COMBO 1, 42.41,OTHER, 12.46, 79.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40300,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,WELLMED,WELLMED, 24.33,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40301,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,WELLMED,WELLMED, 22.66,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40302,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,WELLMED,WELLMED, 22.66,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40303,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,WELLMED,WELLMED, 22.74,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40304,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,WELLMED,WELLMED, 22.74,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40305,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,WELLMED,WELLMED, 31.96,,OUTPAT REV HCPCS COMBO 1, 38.14,OTHER, 7.76, 72.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40306,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,WELLMED,WELLMED, 31.96,,OUTPAT REV HCPCS COMBO 1, 38.14,OTHER, 7.76, 72.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40307,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,WELLMED,WELLMED, 23.16,,OUTPAT REV HCPCS COMBO 1, 28.29,OTHER, 8.38, 52.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40308,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,WELLMED,WELLMED, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.72,OTHER, 28.16, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40309,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,WELLMED,WELLMED, 260.02,,OUTPAT REV HCPCS COMBO 1, 299.39,OTHER, 17.26, 592.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40310,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,WELLMED,WELLMED, 32.69,,OUTPAT REV HCPCS COMBO 1, 40.67,OTHER, 14.88, 74.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40311,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,WELLMED,WELLMED, 34.45,,OUTPAT REV HCPCS COMBO 1, 43.08,OTHER, 16.61, 78.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40312,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,WELLMED,WELLMED, 102.77,,OUTPAT REV HCPCS COMBO 1, 121.25,OTHER, 19.08, 234.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40313,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,WELLMED,WELLMED, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.89,OTHER, 28.87, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40314,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,WELLMED,WELLMED, 82.99,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40315,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,WELLMED,WELLMED, 82.99,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40316,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,WELLMED,WELLMED, 82.99,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40317,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,WELLMED,WELLMED, 82.99,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40318,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,WELLMED,WELLMED, 82.99,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40319,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,WELLMED,WELLMED, 162.17,,OUTPAT REV HCPCS COMBO 1, 198.86,OTHER, 61.69, 369.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40320,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,WELLMED,WELLMED, 162.17,,OUTPAT REV HCPCS COMBO 1, 198.86,OTHER, 61.69, 369.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40321,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,WELLMED,WELLMED, 67.57,,OUTPAT REV HCPCS COMBO 1, 100.71,OTHER, 67.57, 153.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40322,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,WELLMED,WELLMED, 182.09,,OUTPAT REV HCPCS COMBO 1, 221.47,OTHER, 61.69, 415.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40323,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,WELLMED,WELLMED, 56.71,,OUTPAT REV HCPCS COMBO 1, 76.43,OTHER, 50.53, 129.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40324,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,WELLMED,WELLMED, 207.69,,OUTPAT REV HCPCS COMBO 1, 265.03,OTHER, 122.54, 473.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40325,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,WELLMED,WELLMED, 82.99,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40326,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,WELLMED,WELLMED, 64.50,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40327,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,WELLMED,WELLMED, 64.50,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40328,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,WELLMED,WELLMED, 266.63,,OUTPAT REV HCPCS COMBO 1, 445.68,OTHER, 266.63, 607.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40329,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,WELLMED,WELLMED, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40330,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,WELLMED,WELLMED, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40331,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,WELLMED,WELLMED, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40332,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,WELLMED,WELLMED, 160.23,,OUTPAT REV HCPCS COMBO 1, 193.99,OTHER, 50.53, 365.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40333,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,WELLMED,WELLMED, 160.23,,OUTPAT REV HCPCS COMBO 1, 193.99,OTHER, 50.53, 365.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40334,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40335,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,WELLMED,WELLMED, 142.33,,OUTPAT REV HCPCS COMBO 1, 173.66,OTHER, 50.53, 324.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40336,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,WELLMED,WELLMED, 54.61,,OUTPAT REV HCPCS COMBO 1, 68.89,OTHER, 28.87, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40337,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,WELLMED,WELLMED, 75.34,,OUTPAT REV HCPCS COMBO 1, 204.22,OTHER, 50.53, 599.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40338,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,WELLMED,WELLMED, 263.13,,OUTPAT REV HCPCS COMBO 1, 204.22,OTHER, 50.53, 599.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40339,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,WELLMED,WELLMED, 116.09,,OUTPAT REV HCPCS COMBO 1, 146.52,OTHER, 61.69, 264.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40340,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,WELLMED,WELLMED, 116.09,,OUTPAT REV HCPCS COMBO 1, 146.52,OTHER, 61.69, 264.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40341,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,WELLMED,WELLMED, 49.82,,OUTPAT REV HCPCS COMBO 1, 62.25,OTHER, 23.83, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40342,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,WELLMED,WELLMED, 49.82,,OUTPAT REV HCPCS COMBO 1, 62.25,OTHER, 23.83, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40343,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,WELLMED,WELLMED, 33.97,,OUTPAT REV HCPCS COMBO 1, 43.07,OTHER, 18.86, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40344,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,WELLMED,WELLMED, 33.97,,OUTPAT REV HCPCS COMBO 1, 43.07,OTHER, 18.86, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40345,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,WELLMED,WELLMED, 33.97,,OUTPAT REV HCPCS COMBO 1, 44.25,OTHER, 23.81, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40346,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,WELLMED,WELLMED, 10.75,,OUTPAT REV HCPCS COMBO 1, 17.88,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40347,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,WELLMED,WELLMED, 83.33,,OUTPAT REV HCPCS COMBO 1, 100.14,OTHER, 23.14, 189.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40348,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,WELLMED,WELLMED, 627.37,,OUTPAT REV HCPCS COMBO 1, 800.72,OTHER, 370.73, 1429.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40349,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,WELLMED,WELLMED, 627.37,,OUTPAT REV HCPCS COMBO 1, 800.72,OTHER, 370.73, 1429.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40350,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,WELLMED,WELLMED, 44.72,,OUTPAT REV HCPCS COMBO 1, 59.91,OTHER, 38.32, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40351,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,WELLMED,WELLMED, 44.72,,OUTPAT REV HCPCS COMBO 1, 59.91,OTHER, 38.32, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40352,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,WELLMED,WELLMED, 238.65,,OUTPAT REV HCPCS COMBO 1, 294.34,OTHER, 97.97, 543.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40353,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40354,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40355,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,WELLMED,WELLMED, 13.33,,OUTPAT REV HCPCS COMBO 1, 16.75,OTHER, 6.79, 30.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40356,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,WELLMED,WELLMED, 13.33,,OUTPAT REV HCPCS COMBO 1, 16.75,OTHER, 6.79, 30.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40357,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,WELLMED,WELLMED, 48.34,,OUTPAT REV HCPCS COMBO 1, 56.81,OTHER, 8.06, 110.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40358,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,WELLMED,WELLMED, 32.99,,OUTPAT REV HCPCS COMBO 1, 39.98,OTHER, 10.56, 75.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40359,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,WELLMED,WELLMED, 33.11,,OUTPAT REV HCPCS COMBO 1, 41.73,OTHER, 17.35, 75.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40360,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,WELLMED,WELLMED, 2550.94,,OUTPAT REV HCPCS COMBO 1, 3802.17,OTHER, 2550.94, 5813.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40361,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,WELLMED,WELLMED, 48.44,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40362,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,WELLMED,WELLMED, 48.44,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40363,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,WELLMED,WELLMED, 12.69,,OUTPAT REV HCPCS COMBO 1, 23.30,OTHER, 12.69, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40364,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,WELLMED,WELLMED, 25.59,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40365,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,WELLMED,WELLMED, 12.79,,OUTPAT REV HCPCS COMBO 1, 23.42,OTHER, 12.79, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40366,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,WELLMED,WELLMED, 55.47,,OUTPAT REV HCPCS COMBO 1, 82.68,OTHER, 55.47, 126.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40367,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40368,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,WELLMED,WELLMED, 65.79,,OUTPAT REV HCPCS COMBO 1, 149.84,OTHER, 65.79, 315.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40369,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,WELLMED,WELLMED, 65.79,,OUTPAT REV HCPCS COMBO 1, 149.84,OTHER, 65.79, 315.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40370,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,WELLMED,WELLMED, 59.75,,OUTPAT REV HCPCS COMBO 1, 89.06,OTHER, 59.75, 136.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40371,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,WELLMED,WELLMED, 21.50,,OUTPAT REV HCPCS COMBO 1, 41.40,OTHER, 21.50, 71.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40372,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,WELLMED,WELLMED, 21.50,,OUTPAT REV HCPCS COMBO 1, 41.40,OTHER, 21.50, 71.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40373,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,WELLMED,WELLMED, 255.16,,OUTPAT REV HCPCS COMBO 1, 356.50,OTHER, 255.16, 581.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40374,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,WELLMED,WELLMED, 533.11,,OUTPAT REV HCPCS COMBO 1, 687.64,OTHER, 345.38, 1214.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40375,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,WELLMED,WELLMED, 135.24,,OUTPAT REV HCPCS COMBO 1, 201.57,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40376,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40377,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40378,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,WELLMED,WELLMED, 36.55,,OUTPAT REV HCPCS COMBO 1, 60.00,OTHER, 36.55, 83.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40379,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,WELLMED,WELLMED, 22.12,,OUTPAT REV HCPCS COMBO 1, 36.74,OTHER, 22.12, 50.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40380,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,WELLMED,WELLMED, 22.12,,OUTPAT REV HCPCS COMBO 1, 36.74,OTHER, 22.12, 50.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40381,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40382,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40383,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40384,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,WELLMED,WELLMED, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40385,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,WELLMED,WELLMED, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40386,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,WELLMED,WELLMED, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40387,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,WELLMED,WELLMED, 4.73,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40388,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,WELLMED,WELLMED, 34.29,,OUTPAT REV HCPCS COMBO 1, 51.11,OTHER, 34.29, 78.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40389,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,WELLMED,WELLMED, 58.79,,OUTPAT REV HCPCS COMBO 1, 87.62,OTHER, 58.79, 133.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40390,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,WELLMED,WELLMED, 58.79,,OUTPAT REV HCPCS COMBO 1, 87.62,OTHER, 58.79, 133.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40391,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40392,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,WELLMED,WELLMED, 67.85,,OUTPAT REV HCPCS COMBO 1, 111.30,OTHER, 67.85, 154.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40393,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,WELLMED,WELLMED, 67.85,,OUTPAT REV HCPCS COMBO 1, 111.30,OTHER, 67.85, 154.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40394,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40395,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40396,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,WELLMED,WELLMED, 73.49,,OUTPAT REV HCPCS COMBO 1, 104.75,OTHER, 73.49, 167.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40397,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,WELLMED,WELLMED, 73.49,,OUTPAT REV HCPCS COMBO 1, 104.75,OTHER, 73.49, 167.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40398,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,WELLMED,WELLMED, 4.30,,OUTPAT REV HCPCS COMBO 1, 12.78,OTHER, 4.30, 33.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40399,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,WELLMED,WELLMED, 14.22,,OUTPAT REV HCPCS COMBO 1, 17.36,OTHER, 5.09, 32.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40400,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,WELLMED,WELLMED, 130.68,,OUTPAT REV HCPCS COMBO 1, 184.48,OTHER, 130.68, 297.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40401,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,WELLMED,WELLMED, 146.42,,OUTPAT REV HCPCS COMBO 1, 202.35,OTHER, 146.42, 333.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40402,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,WELLMED,WELLMED, 63.61,,OUTPAT REV HCPCS COMBO 1, 99.37,OTHER, 63.61, 144.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40403,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,WELLMED,WELLMED, 65.39,,OUTPAT REV HCPCS COMBO 1, 88.44,OTHER, 59.56, 149.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40404,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,WELLMED,WELLMED, 84.22,,OUTPAT REV HCPCS COMBO 1, 131.72,OTHER, 84.22, 191.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40405,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,WELLMED,WELLMED, 82.81,,OUTPAT REV HCPCS COMBO 1, 117.05,OTHER, 82.81, 188.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40406,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,WELLMED,WELLMED, 126.51,,OUTPAT REV HCPCS COMBO 1, 179.75,OTHER, 126.51, 288.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40407,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,WELLMED,WELLMED, 109.46,,OUTPAT REV HCPCS COMBO 1, 158.52,OTHER, 109.46, 249.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40408,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,WELLMED,WELLMED, 132.20,,OUTPAT REV HCPCS COMBO 1, 186.21,OTHER, 132.20, 301.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40409,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,WELLMED,WELLMED, 63.26,,OUTPAT REV HCPCS COMBO 1, 83.96,OTHER, 50.93, 144.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40410,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,WELLMED,WELLMED, 102.00,,OUTPAT REV HCPCS COMBO 1, 167.44,OTHER, 102.00, 232.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40411,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,WELLMED,WELLMED, 106.26,,OUTPAT REV HCPCS COMBO 1, 172.28,OTHER, 106.26, 242.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40412,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,WELLMED,WELLMED, 25.59,,OUTPAT REV HCPCS COMBO 1, 49.86,OTHER, 25.59, 87.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40413,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,WELLMED,WELLMED, 106.61,,OUTPAT REV HCPCS COMBO 1, 141.43,OTHER, 85.51, 242.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40414,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,WELLMED,WELLMED, 45.42,,OUTPAT REV HCPCS COMBO 1, 69.71,OTHER, 45.42, 103.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40415,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,WELLMED,WELLMED, 120.47,,OUTPAT REV HCPCS COMBO 1, 177.65,OTHER, 120.47, 274.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40416,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,WELLMED,WELLMED, 130.87,,OUTPAT REV HCPCS COMBO 1, 189.46,OTHER, 130.87, 298.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40417,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,WELLMED,WELLMED, 210.54,,OUTPAT REV HCPCS COMBO 1, 279.93,OTHER, 171.54, 479.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40418,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,WELLMED,WELLMED, 197.39,,OUTPAT REV HCPCS COMBO 1, 265.00,OTHER, 171.54, 449.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40419,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,WELLMED,WELLMED, 108.18,,OUTPAT REV HCPCS COMBO 1, 149.90,OTHER, 108.18, 246.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40420,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,WELLMED,WELLMED, 137.41,,OUTPAT REV HCPCS COMBO 1, 167.02,OTHER, 46.09, 313.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40421,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,WELLMED,WELLMED, 57.35,,OUTPAT REV HCPCS COMBO 1, 76.10,OTHER, 46.09, 130.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40422,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,WELLMED,WELLMED, 120.09,,OUTPAT REV HCPCS COMBO 1, 147.35,OTHER, 46.09, 273.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40423,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,WELLMED,WELLMED, 174.02,,OUTPAT REV HCPCS COMBO 1, 227.22,OTHER, 124.32, 396.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40424,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,WELLMED,WELLMED, 234.14,,OUTPAT REV HCPCS COMBO 1, 295.49,OTHER, 124.32, 533.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40425,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,WELLMED,WELLMED, 74.67,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 74.67, 170.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40426,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,WELLMED,WELLMED, 110.85,,OUTPAT REV HCPCS COMBO 1, 155.48,OTHER, 110.85, 252.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40427,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,WELLMED,WELLMED, 17.18,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40428,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,WELLMED,WELLMED, 17.18,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40429,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,WELLMED,WELLMED, 17.18,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40430,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,WELLMED,WELLMED, 8.41,,OUTPAT REV HCPCS COMBO 1, 36.72,OTHER, 8.41, 114.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40431,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,WELLMED,WELLMED, 158.39,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 114.13, 360.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40432,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,WELLMED,WELLMED, 158.39,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 114.13, 360.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40433,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,WELLMED,WELLMED, 391.14,,OUTPAT REV HCPCS COMBO 1, 526.62,OTHER, 346.21, 891.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40434,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40435,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40436,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,WELLMED,WELLMED, 132.44,,OUTPAT REV HCPCS COMBO 1, 162.12,OTHER, 49.24, 301.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40437,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,WELLMED,WELLMED, 106.64,,OUTPAT REV HCPCS COMBO 1, 140.39,OTHER, 80.99, 243.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40438,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,WELLMED,WELLMED, 106.64,,OUTPAT REV HCPCS COMBO 1, 140.39,OTHER, 80.99, 243.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40439,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,WELLMED,WELLMED, 136.31,,OUTPAT REV HCPCS COMBO 1, 166.97,OTHER, 51.13, 310.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40440,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,WELLMED,WELLMED, 37.67,,OUTPAT REV HCPCS COMBO 1, 54.96,OTHER, 37.67, 85.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40441,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,WELLMED,WELLMED, 65.39,,OUTPAT REV HCPCS COMBO 1, 86.43,OTHER, 51.13, 149.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40442,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,WELLMED,WELLMED, 699.47,,OUTPAT REV HCPCS COMBO 1, 950.56,OTHER, 656.16, 1594.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40443,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40444,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,WELLMED,WELLMED, 399.90,,OUTPAT REV HCPCS COMBO 1, 545.72,OTHER, 384.68, 911.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40445,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,WELLMED,WELLMED, 399.90,,OUTPAT REV HCPCS COMBO 1, 545.72,OTHER, 384.68, 911.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40446,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40447,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40448,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,WELLMED,WELLMED, 473.98,,OUTPAT REV HCPCS COMBO 1, 591.97,OTHER, 225.62, 1080.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40449,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40450,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,WELLMED,WELLMED, 200.25,,OUTPAT REV HCPCS COMBO 1, 250.40,OTHER, 96.59, 456.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40451,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,WELLMED,WELLMED, 200.25,,OUTPAT REV HCPCS COMBO 1, 250.40,OTHER, 96.59, 456.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40452,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40453,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,WELLMED,WELLMED, 449.04,,OUTPAT REV HCPCS COMBO 1, 563.65,OTHER, 225.62, 1023.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40454,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40455,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,WELLMED,WELLMED, 70.09,,OUTPAT REV HCPCS COMBO 1, 113.30,OTHER, 70.09, 159.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40456,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,WELLMED,WELLMED, 70.09,,OUTPAT REV HCPCS COMBO 1, 113.30,OTHER, 70.09, 159.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40457,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40458,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40459,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,WELLMED,WELLMED, 215.00,,OUTPAT REV HCPCS COMBO 1, 297.88,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40460,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40461,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,WELLMED,WELLMED, 201.13,,OUTPAT REV HCPCS COMBO 1, 262.11,OTHER, 141.55, 458.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40462,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,WELLMED,WELLMED, 201.13,,OUTPAT REV HCPCS COMBO 1, 262.11,OTHER, 141.55, 458.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40463,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40464,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40465,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,WELLMED,WELLMED, 545.87,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40466,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,WELLMED,WELLMED, 545.87,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40467,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,WELLMED,WELLMED, 290.03,,OUTPAT REV HCPCS COMBO 1, 383.08,OTHER, 225.62, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40468,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,WELLMED,WELLMED, 545.87,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40469,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40470,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40471,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40472,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40473,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,WELLMED,WELLMED, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40474,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,WELLMED,WELLMED, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40475,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,WELLMED,WELLMED, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40476,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,WELLMED,WELLMED, 290.03,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40477,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40478,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40479,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40480,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40481,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,WELLMED,WELLMED, 529.82,,OUTPAT REV HCPCS COMBO 1, 655.39,OTHER, 225.62, 1207.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40482,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40483,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,WELLMED,WELLMED, 1114.13,,OUTPAT REV HCPCS COMBO 1, 1042.14,OTHER, 284.89, 2539.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40484,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,WELLMED,WELLMED, 601.78,,OUTPAT REV HCPCS COMBO 1, 1042.14,OTHER, 284.89, 2539.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40485,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,WELLMED,WELLMED, 187.48,,OUTPAT REV HCPCS COMBO 1, 184.77,OTHER, 39.56, 427.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40486,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,WELLMED,WELLMED, 39.56,,OUTPAT REV HCPCS COMBO 1, 184.77,OTHER, 39.56, 427.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40487,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,WELLMED,WELLMED, 452.95,,OUTPAT REV HCPCS COMBO 1, 547.41,OTHER, 138.71, 1032.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40488,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,WELLMED,WELLMED, 103.88,,OUTPAT REV HCPCS COMBO 1, 154.36,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40489,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,WELLMED,WELLMED, 103.88,,OUTPAT REV HCPCS COMBO 1, 154.36,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40490,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,WELLMED,WELLMED, 125.79,,OUTPAT REV HCPCS COMBO 1, 199.86,OTHER, 125.79, 286.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40491,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,WELLMED,WELLMED, 125.79,,OUTPAT REV HCPCS COMBO 1, 199.86,OTHER, 125.79, 286.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40492,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,WELLMED,WELLMED, 263.32,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40493,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,WELLMED,WELLMED, 345.29,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40494,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,WELLMED,WELLMED, 379.26,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40495,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,WELLMED,WELLMED, 263.32,,OUTPAT REV HCPCS COMBO 1, 332.46,OTHER, 140.42, 600.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40496,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,WELLMED,WELLMED, 160.29,,OUTPAT REV HCPCS COMBO 1, 239.03,OTHER, 160.29, 365.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40497,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,WELLMED,WELLMED, 160.29,,OUTPAT REV HCPCS COMBO 1, 239.03,OTHER, 160.29, 365.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40498,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,WELLMED,WELLMED, 103.88,,OUTPAT REV HCPCS COMBO 1, 174.98,OTHER, 103.88, 239.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40499,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,WELLMED,WELLMED, 103.88,,OUTPAT REV HCPCS COMBO 1, 136.10,OTHER, 76.16, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40500,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,WELLMED,WELLMED, 74.39,,OUTPAT REV HCPCS COMBO 1, 140.33,OTHER, 74.39, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40501,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,WELLMED,WELLMED, 182.75,,OUTPAT REV HCPCS COMBO 1, 228.33,OTHER, 87.35, 416.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40502,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,WELLMED,WELLMED, 22.94,,OUTPAT REV HCPCS COMBO 1, 34.19,OTHER, 22.94, 52.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40503,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,WELLMED,WELLMED, 44.72,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40504,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,WELLMED,WELLMED, 140.89,,OUTPAT REV HCPCS COMBO 1, 182.46,OTHER, 94.34, 321.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40505,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,WELLMED,WELLMED, 140.89,,OUTPAT REV HCPCS COMBO 1, 182.46,OTHER, 94.34, 321.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40506,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,WELLMED,WELLMED, 61.67,,OUTPAT REV HCPCS COMBO 1, 125.89,OTHER, 61.67, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40507,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,WELLMED,WELLMED, 61.67,,OUTPAT REV HCPCS COMBO 1, 125.89,OTHER, 61.67, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40508,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,WELLMED,WELLMED, 316.56,,OUTPAT REV HCPCS COMBO 1, 415.63,OTHER, 235.80, 721.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40509,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,WELLMED,WELLMED, 1397.50,,OUTPAT REV HCPCS COMBO 1, 1853.96,OTHER, 1121.15, 3185.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40510,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,WELLMED,WELLMED, 1397.50,,OUTPAT REV HCPCS COMBO 1, 1853.96,OTHER, 1121.15, 3185.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40511,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,WELLMED,WELLMED, 1677.00,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40512,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,WELLMED,WELLMED, 1677.00,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40513,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,WELLMED,WELLMED, 1677.00,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40514,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,WELLMED,WELLMED, 116.62,,OUTPAT REV HCPCS COMBO 1, 152.82,OTHER, 85.61, 265.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40515,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,WELLMED,WELLMED, 127.40,,OUTPAT REV HCPCS COMBO 1, 165.98,OTHER, 89.47, 290.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40516,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,WELLMED,WELLMED, 206.52,,OUTPAT REV HCPCS COMBO 1, 260.74,OTHER, 110.12, 470.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40517,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,WELLMED,WELLMED, 206.52,,OUTPAT REV HCPCS COMBO 1, 260.74,OTHER, 110.12, 470.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40518,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,WELLMED,WELLMED, 77.49,,OUTPAT REV HCPCS COMBO 1, 96.89,OTHER, 37.34, 176.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40519,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,WELLMED,WELLMED, 77.49,,OUTPAT REV HCPCS COMBO 1, 96.89,OTHER, 37.34, 176.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40520,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,WELLMED,WELLMED, 245.81,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40521,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,WELLMED,WELLMED, 245.81,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40522,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,WELLMED,WELLMED, 245.81,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40523,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,WELLMED,WELLMED, 70.82,,OUTPAT REV HCPCS COMBO 1, 89.33,OTHER, 37.34, 161.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40524,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,WELLMED,WELLMED, 70.85,,OUTPAT REV HCPCS COMBO 1, 89.33,OTHER, 37.34, 161.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40525,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,WELLMED,WELLMED, 84.46,,OUTPAT REV HCPCS COMBO 1, 108.89,OTHER, 54.48, 192.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40526,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,WELLMED,WELLMED, 84.46,,OUTPAT REV HCPCS COMBO 1, 108.89,OTHER, 54.48, 192.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40527,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,WELLMED,WELLMED, 61.89,,OUTPAT REV HCPCS COMBO 1, 92.25,OTHER, 61.89, 141.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40528,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,WELLMED,WELLMED, 61.89,,OUTPAT REV HCPCS COMBO 1, 92.25,OTHER, 61.89, 141.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40529,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,WELLMED,WELLMED, 66.17,,OUTPAT REV HCPCS COMBO 1, 84.04,OTHER, 37.34, 150.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40530,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,WELLMED,WELLMED, 66.17,,OUTPAT REV HCPCS COMBO 1, 84.04,OTHER, 37.34, 150.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40531,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,WELLMED,WELLMED, 25.59,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40532,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,WELLMED,WELLMED, 25.59,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40533,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,WELLMED,WELLMED, 129.36,,OUTPAT REV HCPCS COMBO 1, 159.88,OTHER, 54.48, 294.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40534,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,WELLMED,WELLMED, 129.36,,OUTPAT REV HCPCS COMBO 1, 159.88,OTHER, 54.48, 294.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40535,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,WELLMED,WELLMED, 73.50,,OUTPAT REV HCPCS COMBO 1, 96.44,OTHER, 54.48, 167.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40536,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,WELLMED,WELLMED, 73.50,,OUTPAT REV HCPCS COMBO 1, 96.44,OTHER, 54.48, 167.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40537,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,WELLMED,WELLMED, 74.18,,OUTPAT REV HCPCS COMBO 1, 110.56,OTHER, 74.18, 169.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40538,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,WELLMED,WELLMED, 74.18,,OUTPAT REV HCPCS COMBO 1, 110.56,OTHER, 74.18, 169.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40539,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,WELLMED,WELLMED, 37.82,,OUTPAT REV HCPCS COMBO 1, 47.95,OTHER, 21.01, 86.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40540,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,WELLMED,WELLMED, 37.82,,OUTPAT REV HCPCS COMBO 1, 47.95,OTHER, 21.01, 86.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40541,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,WELLMED,WELLMED, 41.51,,OUTPAT REV HCPCS COMBO 1, 55.33,OTHER, 34.39, 94.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40542,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,WELLMED,WELLMED, 41.51,,OUTPAT REV HCPCS COMBO 1, 55.33,OTHER, 34.39, 94.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40543,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,WELLMED,WELLMED, 45.49,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40544,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,WELLMED,WELLMED, 45.49,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40545,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,WELLMED,WELLMED, 45.49,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40546,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,WELLMED,WELLMED, 180.60,,OUTPAT REV HCPCS COMBO 1, 142.33,OTHER, 28.82, 411.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40547,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,WELLMED,WELLMED, 57.99,,OUTPAT REV HCPCS COMBO 1, 142.33,OTHER, 28.82, 411.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40548,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,WELLMED,WELLMED, 57.99,,OUTPAT REV HCPCS COMBO 1, 72.71,OTHER, 28.82, 132.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40549,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,WELLMED,WELLMED, 52.84,,OUTPAT REV HCPCS COMBO 1, 74.33,OTHER, 52.80, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40550,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,WELLMED,WELLMED, 52.80,,OUTPAT REV HCPCS COMBO 1, 74.33,OTHER, 52.80, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40551,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,WELLMED,WELLMED, 52.84,,OUTPAT REV HCPCS COMBO 1, 74.35,OTHER, 52.84, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40552,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,WELLMED,WELLMED, 56.36,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40553,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,WELLMED,WELLMED, 56.36,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40554,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,WELLMED,WELLMED, 56.36,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40555,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,WELLMED,WELLMED, 40.91,,OUTPAT REV HCPCS COMBO 1, 60.80,OTHER, 40.91, 93.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40556,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,WELLMED,WELLMED, 40.91,,OUTPAT REV HCPCS COMBO 1, 60.80,OTHER, 40.91, 93.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40557,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,WELLMED,WELLMED, 29.08,,OUTPAT REV HCPCS COMBO 1, 47.68,OTHER, 29.08, 66.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40558,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,WELLMED,WELLMED, 76.97,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40559,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,WELLMED,WELLMED, 76.97,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40560,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,WELLMED,WELLMED, 76.97,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40561,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,WELLMED,WELLMED, 92.45,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40562,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,WELLMED,WELLMED, 92.45,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40563,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,WELLMED,WELLMED, 92.45,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40564,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,WELLMED,WELLMED, 52.75,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40565,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,WELLMED,WELLMED, 52.75,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40566,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,WELLMED,WELLMED, 52.75,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40567,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,WELLMED,WELLMED, 18.92,,OUTPAT REV HCPCS COMBO 1, 30.33,OTHER, 18.92, 43.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40568,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,WELLMED,WELLMED, 113.97,,OUTPAT REV HCPCS COMBO 1, 178.52,OTHER, 113.97, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40569,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,WELLMED,WELLMED, 135.24,,OUTPAT REV HCPCS COMBO 1, 202.67,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40570,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,WELLMED,WELLMED, 128.04,,OUTPAT REV HCPCS COMBO 1, 194.50,OTHER, 128.04, 291.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40571,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,WELLMED,WELLMED, 63.79,,OUTPAT REV HCPCS COMBO 1, 106.37,OTHER, 63.79, 145.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40572,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,WELLMED,WELLMED, 109.36,,OUTPAT REV HCPCS COMBO 1, 173.75,OTHER, 109.36, 249.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40573,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,WELLMED,WELLMED, 115.60,,OUTPAT REV HCPCS COMBO 1, 180.83,OTHER, 115.60, 263.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40574,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,WELLMED,WELLMED, 136.43,,OUTPAT REV HCPCS COMBO 1, 204.49,OTHER, 136.43, 310.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40575,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,WELLMED,WELLMED, 65.89,,OUTPAT REV HCPCS COMBO 1, 108.91,OTHER, 65.89, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40576,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,WELLMED,WELLMED, 51.91,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40577,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,WELLMED,WELLMED, 51.91,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40578,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,WELLMED,WELLMED, 51.91,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40579,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,WELLMED,WELLMED, 31.56,,OUTPAT REV HCPCS COMBO 1, 44.69,OTHER, 31.56, 71.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40580,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,WELLMED,WELLMED, 54.89,,OUTPAT REV HCPCS COMBO 1, 78.22,OTHER, 54.89, 125.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40581,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,WELLMED,WELLMED, 54.89,,OUTPAT REV HCPCS COMBO 1, 78.22,OTHER, 54.89, 125.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40582,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,WELLMED,WELLMED, 38.11,,OUTPAT REV HCPCS COMBO 1, 59.17,OTHER, 38.11, 86.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40583,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,WELLMED,WELLMED, 49.88,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40584,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,WELLMED,WELLMED, 49.88,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40585,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,WELLMED,WELLMED, 49.88,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40586,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40587,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,WELLMED,WELLMED, 61.82,,OUTPAT REV HCPCS COMBO 1, 93.12,OTHER, 61.82, 140.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40588,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,WELLMED,WELLMED, 52.03,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 52.03, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40589,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,WELLMED,WELLMED, 113.97,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 52.03, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40590,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,WELLMED,WELLMED, 53.32,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40591,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,WELLMED,WELLMED, 53.32,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40592,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,WELLMED,WELLMED, 53.32,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40593,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,WELLMED,WELLMED, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40594,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,WELLMED,WELLMED, 44.72,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40595,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,WELLMED,WELLMED, 60.63,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40596,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,WELLMED,WELLMED, 44.72,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40597,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,WELLMED,WELLMED, 60.63,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40598,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,WELLMED,WELLMED, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40599,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,WELLMED,WELLMED, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40600,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,WELLMED,WELLMED, 129.00,,OUTPAT REV HCPCS COMBO 1, 192.27,OTHER, 129.00, 294.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40601,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40602,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40603,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,WELLMED,WELLMED, 103.88,,OUTPAT REV HCPCS COMBO 1, 145.27,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40604,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,WELLMED,WELLMED, 63.96,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40605,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,WELLMED,WELLMED, 63.96,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40606,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,WELLMED,WELLMED, 108.39,,OUTPAT REV HCPCS COMBO 1, 161.56,OTHER, 108.39, 247.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40607,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,WELLMED,WELLMED, 108.39,,OUTPAT REV HCPCS COMBO 1, 161.56,OTHER, 108.39, 247.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40608,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,WELLMED,WELLMED, 169.59,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40609,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,WELLMED,WELLMED, 169.59,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40610,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,WELLMED,WELLMED, 211.26,,OUTPAT REV HCPCS COMBO 1, 314.88,OTHER, 211.26, 481.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40611,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,WELLMED,WELLMED, 211.26,,OUTPAT REV HCPCS COMBO 1, 314.88,OTHER, 211.26, 481.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40612,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,WELLMED,WELLMED, 20.47,,OUTPAT REV HCPCS COMBO 1, 30.51,OTHER, 20.47, 46.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40613,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,WELLMED,WELLMED, 44.59,,OUTPAT REV HCPCS COMBO 1, 66.46,OTHER, 44.59, 101.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40614,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,WELLMED,WELLMED, 44.59,,OUTPAT REV HCPCS COMBO 1, 66.46,OTHER, 44.59, 101.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40615,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,WELLMED,WELLMED, 74.56,,OUTPAT REV HCPCS COMBO 1, 111.13,OTHER, 74.56, 169.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40616,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,WELLMED,WELLMED, 74.56,,OUTPAT REV HCPCS COMBO 1, 111.13,OTHER, 74.56, 169.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40617,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,WELLMED,WELLMED, 110.02,,OUTPAT REV HCPCS COMBO 1, 163.98,OTHER, 110.02, 250.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40618,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,WELLMED,WELLMED, 110.02,,OUTPAT REV HCPCS COMBO 1, 163.98,OTHER, 110.02, 250.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40619,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,WELLMED,WELLMED, 147.30,,OUTPAT REV HCPCS COMBO 1, 219.55,OTHER, 147.30, 335.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40620,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,WELLMED,WELLMED, 147.30,,OUTPAT REV HCPCS COMBO 1, 219.55,OTHER, 147.30, 335.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40621,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40622,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40623,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40624,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40625,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40626,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,WELLMED,WELLMED, 115.64,,OUTPAT REV HCPCS COMBO 1, 149.74,OTHER, 77.35, 263.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40627,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,WELLMED,WELLMED, 115.64,,OUTPAT REV HCPCS COMBO 1, 149.74,OTHER, 77.35, 263.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40628,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40629,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40630,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,WELLMED,WELLMED, 178.88,,OUTPAT REV HCPCS COMBO 1, 233.57,OTHER, 127.82, 407.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40631,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,WELLMED,WELLMED, 178.88,,OUTPAT REV HCPCS COMBO 1, 233.57,OTHER, 127.82, 407.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40632,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40633,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40634,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,WELLMED,WELLMED, 282.66,,OUTPAT REV HCPCS COMBO 1, 369.55,OTHER, 203.96, 644.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40635,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,WELLMED,WELLMED, 282.66,,OUTPAT REV HCPCS COMBO 1, 369.55,OTHER, 203.96, 644.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40636,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40637,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40638,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,WELLMED,WELLMED, 443.36,,OUTPAT REV HCPCS COMBO 1, 580.80,OTHER, 324.71, 1010.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40639,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,WELLMED,WELLMED, 443.36,,OUTPAT REV HCPCS COMBO 1, 580.80,OTHER, 324.71, 1010.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40640,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40641,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40642,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,WELLMED,WELLMED, 739.51,,OUTPAT REV HCPCS COMBO 1, 954.02,OTHER, 479.76, 1685.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40643,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,WELLMED,WELLMED, 739.51,,OUTPAT REV HCPCS COMBO 1, 954.02,OTHER, 479.76, 1685.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40644,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40645,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,WELLMED,WELLMED, 1182.84,,OUTPAT REV HCPCS COMBO 1, 1514.86,OTHER, 720.78, 2695.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40646,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,WELLMED,WELLMED, 433.62,,OUTPAT REV HCPCS COMBO 1, 646.30,OTHER, 433.62, 988.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40647,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,WELLMED,WELLMED, 12.90,,OUTPAT REV HCPCS COMBO 1, 19.23,OTHER, 12.90, 29.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40648,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,WELLMED,WELLMED, 72.00,,OUTPAT REV HCPCS COMBO 1, 107.32,OTHER, 72.00, 164.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40649,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,WELLMED,WELLMED, 72.00,,OUTPAT REV HCPCS COMBO 1, 107.32,OTHER, 72.00, 164.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40650,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,WELLMED,WELLMED, 113.31,,OUTPAT REV HCPCS COMBO 1, 167.97,OTHER, 113.31, 258.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40651,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,WELLMED,WELLMED, 118.06,,OUTPAT REV HCPCS COMBO 1, 173.37,OTHER, 118.06, 269.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40652,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,WELLMED,WELLMED, 123.17,,OUTPAT REV HCPCS COMBO 1, 179.18,OTHER, 123.17, 280.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40653,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,WELLMED,WELLMED, 139.26,,OUTPAT REV HCPCS COMBO 1, 197.44,OTHER, 139.26, 317.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40654,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,WELLMED,WELLMED, 135.24,,OUTPAT REV HCPCS COMBO 1, 192.88,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40655,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,WELLMED,WELLMED, 156.07,,OUTPAT REV HCPCS COMBO 1, 232.62,OTHER, 156.07, 355.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40656,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,WELLMED,WELLMED, 169.59,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40657,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,WELLMED,WELLMED, 101.97,,OUTPAT REV HCPCS COMBO 1, 155.10,OTHER, 101.97, 232.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40658,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,WELLMED,WELLMED, 108.92,,OUTPAT REV HCPCS COMBO 1, 162.99,OTHER, 108.92, 248.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40659,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,WELLMED,WELLMED, 118.79,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40660,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,WELLMED,WELLMED, 118.79,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40661,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,WELLMED,WELLMED, 118.79,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40662,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,WELLMED,WELLMED, 121.35,,OUTPAT REV HCPCS COMBO 1, 177.10,OTHER, 121.35, 276.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40663,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,WELLMED,WELLMED, 129.39,,OUTPAT REV HCPCS COMBO 1, 192.85,OTHER, 129.39, 294.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40664,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,WELLMED,WELLMED, 139.26,,OUTPAT REV HCPCS COMBO 1, 207.56,OTHER, 139.26, 317.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40665,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,WELLMED,WELLMED, 37.28,,OUTPAT REV HCPCS COMBO 1, 55.57,OTHER, 37.28, 84.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40666,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,WELLMED,WELLMED, 63.96,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40667,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,WELLMED,WELLMED, 30.10,,OUTPAT REV HCPCS COMBO 1, 44.86,OTHER, 30.10, 68.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40668,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,WELLMED,WELLMED, 114.40,,OUTPAT REV HCPCS COMBO 1, 170.52,OTHER, 114.40, 260.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40669,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,WELLMED,WELLMED, 22.74,,OUTPAT REV HCPCS COMBO 1, 33.14,OTHER, 22.74, 51.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40670,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,WELLMED,WELLMED, 28.14,,OUTPAT REV HCPCS COMBO 1, 39.28,OTHER, 28.14, 64.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40671,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,WELLMED,WELLMED, 40.58,,OUTPAT REV HCPCS COMBO 1, 60.49,OTHER, 40.58, 92.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40672,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,WELLMED,WELLMED, 9.46,,OUTPAT REV HCPCS COMBO 1, 14.10,OTHER, 9.46, 21.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40673,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,WELLMED,WELLMED, 9.46,,OUTPAT REV HCPCS COMBO 1, 54.72,OTHER, 9.46, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40674,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,WELLMED,WELLMED, 63.96,,OUTPAT REV HCPCS COMBO 1, 54.72,OTHER, 9.46, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40675,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,WELLMED,WELLMED, 109.65,,OUTPAT REV HCPCS COMBO 1, 148.65,OTHER, 101.33, 249.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40676,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,WELLMED,WELLMED, 118.25,,OUTPAT REV HCPCS COMBO 1, 166.04,OTHER, 118.25, 269.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40677,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,WELLMED,WELLMED, 5.48,,OUTPAT REV HCPCS COMBO 1, 8.17,OTHER, 5.48, 12.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40678,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,WELLMED,WELLMED, 5.48,,OUTPAT REV HCPCS COMBO 1, 8.17,OTHER, 5.48, 12.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40679,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,WELLMED,WELLMED, 165.55,,OUTPAT REV HCPCS COMBO 1, 350.13,OTHER, 165.55, 680.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40680,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,WELLMED,WELLMED, 165.55,,OUTPAT REV HCPCS COMBO 1, 350.13,OTHER, 165.55, 680.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40681,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,WELLMED,WELLMED, 261.01,,OUTPAT REV HCPCS COMBO 1, 553.11,OTHER, 261.01, 1078.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40682,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,WELLMED,WELLMED, 261.01,,OUTPAT REV HCPCS COMBO 1, 553.11,OTHER, 261.01, 1078.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40683,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,WELLMED,WELLMED, 152.65,,OUTPAT REV HCPCS COMBO 1, 308.45,OTHER, 152.65, 567.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40684,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,WELLMED,WELLMED, 152.65,,OUTPAT REV HCPCS COMBO 1, 308.45,OTHER, 152.65, 567.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40685,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,WELLMED,WELLMED, 220.16,,OUTPAT REV HCPCS COMBO 1, 466.19,OTHER, 220.16, 907.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40686,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,WELLMED,WELLMED, 220.16,,OUTPAT REV HCPCS COMBO 1, 466.19,OTHER, 220.16, 907.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40687,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,WELLMED,WELLMED, 377.54,,OUTPAT REV HCPCS COMBO 1, 562.72,OTHER, 377.54, 860.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40688,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,WELLMED,WELLMED, 377.54,,OUTPAT REV HCPCS COMBO 1, 562.72,OTHER, 377.54, 860.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40689,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,WELLMED,WELLMED, 419.25,,OUTPAT REV HCPCS COMBO 1, 624.89,OTHER, 419.25, 955.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40690,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,WELLMED,WELLMED, 419.25,,OUTPAT REV HCPCS COMBO 1, 624.89,OTHER, 419.25, 955.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40691,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,WELLMED,WELLMED, 58.48,,OUTPAT REV HCPCS COMBO 1, 87.16,OTHER, 58.48, 133.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40692,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,WELLMED,WELLMED, 27.52,,OUTPAT REV HCPCS COMBO 1, 41.02,OTHER, 27.52, 62.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40693,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,WELLMED,WELLMED, 32.25,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40694,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,WELLMED,WELLMED, 1288.28,,OUTPAT REV HCPCS COMBO 1, 1648.47,OTHER, 779.04, 2936.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40695,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,WELLMED,WELLMED, 1288.28,,OUTPAT REV HCPCS COMBO 1, 1648.47,OTHER, 779.04, 2936.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40696,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,WELLMED,WELLMED, 1402.23,,OUTPAT REV HCPCS COMBO 1, 1777.88,OTHER, 779.04, 3195.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40697,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,WELLMED,WELLMED, 1402.23,,OUTPAT REV HCPCS COMBO 1, 1777.88,OTHER, 779.04, 3195.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40698,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,WELLMED,WELLMED, 989.00,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40699,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,WELLMED,WELLMED, 989.00,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40700,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,WELLMED,WELLMED, 989.00,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40701,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,WELLMED,WELLMED, 860.00,,OUTPAT REV HCPCS COMBO 1, 1097.72,OTHER, 508.57, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40702,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,WELLMED,WELLMED, 860.00,,OUTPAT REV HCPCS COMBO 1, 1097.72,OTHER, 508.57, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40703,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,WELLMED,WELLMED, 860.00,,OUTPAT REV HCPCS COMBO 1, 1162.11,OTHER, 779.04, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40704,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,WELLMED,WELLMED, 860.00,,OUTPAT REV HCPCS COMBO 1, 1162.11,OTHER, 779.04, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40705,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,WELLMED,WELLMED, 8.23,,OUTPAT REV HCPCS COMBO 1, 9.74,OTHER, 1.66, 18.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40706,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,WELLMED,WELLMED, 48.44,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40707,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,WELLMED,WELLMED, 2.58,,OUTPAT REV HCPCS COMBO 1, 11.82,OTHER, 2.58, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40708,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,WELLMED,WELLMED, 38.74,,OUTPAT REV HCPCS COMBO 1, 57.75,OTHER, 38.74, 88.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40709,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,WELLMED,WELLMED, 20.10,,OUTPAT REV HCPCS COMBO 1, 29.96,OTHER, 20.10, 45.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40710,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,WELLMED,WELLMED, 71.08,,OUTPAT REV HCPCS COMBO 1, 88.75,OTHER, 33.71, 162.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40711,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,WELLMED,WELLMED, 44.72,,OUTPAT REV HCPCS COMBO 1, 58.81,OTHER, 33.71, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40712,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,WELLMED,WELLMED, 168.13,,OUTPAT REV HCPCS COMBO 1, 250.60,OTHER, 168.13, 383.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40713,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,WELLMED,WELLMED, 169.59,,OUTPAT REV HCPCS COMBO 1, 231.89,OTHER, 165.06, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40714,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,WELLMED,WELLMED, 169.59,,OUTPAT REV HCPCS COMBO 1, 231.89,OTHER, 165.06, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40715,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,WELLMED,WELLMED, 18.28,,OUTPAT REV HCPCS COMBO 1, 35.44,OTHER, 18.28, 61.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40716,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,WELLMED,WELLMED, 26.32,,OUTPAT REV HCPCS COMBO 1, 44.57,OTHER, 26.32, 61.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40717,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,WELLMED,WELLMED, 29.24,,OUTPAT REV HCPCS COMBO 1, 43.58,OTHER, 29.24, 66.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40718,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40719,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,WELLMED,WELLMED, 111.71,,OUTPAT REV HCPCS COMBO 1, 166.51,OTHER, 111.71, 254.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40720,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,WELLMED,WELLMED, 40.32,,OUTPAT REV HCPCS COMBO 1, 60.10,OTHER, 40.32, 91.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40721,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,WELLMED,WELLMED, 3.30,,OUTPAT REV HCPCS COMBO 1, 4.92,OTHER, 3.30, 7.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40722,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,WELLMED,WELLMED, 3.20,,OUTPAT REV HCPCS COMBO 1, 4.77,OTHER, 3.20, 7.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40723,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,WELLMED,WELLMED, 8.74,,OUTPAT REV HCPCS COMBO 1, 13.02,OTHER, 8.74, 19.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40724,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,WELLMED,WELLMED, 90.30,,OUTPAT REV HCPCS COMBO 1, 134.59,OTHER, 90.30, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40725,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,WELLMED,WELLMED, .91,,OUTPAT REV HCPCS COMBO 1, 1.36,OTHER, .91, 2.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40726,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,WELLMED,WELLMED, 1.41,,OUTPAT REV HCPCS COMBO 1, 2.10,OTHER, 1.41, 3.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40727,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,WELLMED,WELLMED, 17.38,,OUTPAT REV HCPCS COMBO 1, 25.91,OTHER, 17.38, 39.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40728,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,WELLMED,WELLMED, 62.40,,OUTPAT REV HCPCS COMBO 1, 93.00,OTHER, 62.40, 142.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40729,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,WELLMED,WELLMED, .98,,OUTPAT REV HCPCS COMBO 1, 1.46,OTHER, .98, 2.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40730,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,WELLMED,WELLMED, .69,,OUTPAT REV HCPCS COMBO 1, 1.03,OTHER, .69, 1.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40731,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,WELLMED,WELLMED, 3.46,,OUTPAT REV HCPCS COMBO 1, 5.15,OTHER, 3.46, 7.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40732,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,WELLMED,WELLMED, 7.69,,OUTPAT REV HCPCS COMBO 1, 11.46,OTHER, 7.69, 17.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40733,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,WELLMED,WELLMED, 2.94,,OUTPAT REV HCPCS COMBO 1, 4.38,OTHER, 2.94, 6.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40734,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,WELLMED,WELLMED, 1.72,,OUTPAT REV HCPCS COMBO 1, 2.56,OTHER, 1.72, 3.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40735,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,WELLMED,WELLMED, 5.02,,OUTPAT REV HCPCS COMBO 1, 7.91,OTHER, 5.02, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40736,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,WELLMED,WELLMED, 5.59,,OUTPAT REV HCPCS COMBO 1, 7.91,OTHER, 5.02, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40737,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,WELLMED,WELLMED, 29.38,,OUTPAT REV HCPCS COMBO 1, 43.79,OTHER, 29.38, 66.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40738,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,WELLMED,WELLMED, 15.45,,OUTPAT REV HCPCS COMBO 1, 23.02,OTHER, 15.45, 35.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40739,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,WELLMED,WELLMED, 4.52,,OUTPAT REV HCPCS COMBO 1, 6.74,OTHER, 4.52, 10.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40740,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,WELLMED,WELLMED, 3.49,,OUTPAT REV HCPCS COMBO 1, 5.20,OTHER, 3.49, 7.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40741,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,WELLMED,WELLMED, 171.57,,OUTPAT REV HCPCS COMBO 1, 575.18,OTHER, 171.57, 1597.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40742,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,WELLMED,WELLMED, 171.57,,OUTPAT REV HCPCS COMBO 1, 690.66,OTHER, 171.57, 2082.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40743,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,WELLMED,WELLMED, 171.57,,OUTPAT REV HCPCS COMBO 1, 656.15,OTHER, 171.57, 1937.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40744,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,WELLMED,WELLMED, 171.57,,OUTPAT REV HCPCS COMBO 1, 607.70,OTHER, 171.57, 1734.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40745,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,WELLMED,WELLMED, 214.57,,OUTPAT REV HCPCS COMBO 1, 735.35,OTHER, 214.57, 2065.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40746,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,WELLMED,WELLMED, 367.65,,OUTPAT REV HCPCS COMBO 1, 421.89,OTHER, 18.42, 837.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40747,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,WELLMED,WELLMED, 2.06,,OUTPAT REV HCPCS COMBO 1, 3.08,OTHER, 2.06, 4.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40748,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,WELLMED,WELLMED, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40749,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,WELLMED,WELLMED, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40750,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,WELLMED,WELLMED, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40751,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,WELLMED,WELLMED, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40752,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,WELLMED,WELLMED, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40753,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,WELLMED,WELLMED, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40754,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,WELLMED,WELLMED, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40755,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,WELLMED,WELLMED, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40756,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,WELLMED,WELLMED, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40757,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,WELLMED,WELLMED, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40758,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,WELLMED,WELLMED, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40759,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,WELLMED,WELLMED, 149.64,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40760,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,WELLMED,WELLMED, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40761,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,WELLMED,WELLMED, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40762,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,WELLMED,WELLMED, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40763,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,WELLMED,WELLMED, 178.45,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40764,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40765,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40766,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40767,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40768,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40769,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40770,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40771,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40772,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40773,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40774,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40775,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40776,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40777,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40778,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40779,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40780,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40781,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40782,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40783,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,WELLMED,WELLMED, 570.18,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40784,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,WELLMED,WELLMED, 45.69,,OUTPAT REV HCPCS COMBO 1, 62.01,OTHER, 42.53, 104.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40785,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,WELLMED,WELLMED, 49.02,,OUTPAT REV HCPCS COMBO 1, 73.06,OTHER, 49.02, 111.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40786,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,WELLMED,WELLMED, 43.00,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40787,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,WELLMED,WELLMED, 215.00,,OUTPAT REV HCPCS COMBO 1, 320.46,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40788,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,WELLMED,WELLMED, 18.06,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40789,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,WELLMED,WELLMED, 1.29,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40790,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,WELLMED,WELLMED, 15.05,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40791,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,WELLMED,WELLMED, 1.29,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40792,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,WELLMED,WELLMED, 11.61,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40793,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,WELLMED,WELLMED, 1.29,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40794,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,WELLMED,WELLMED, 6.45,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40795,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,WELLMED,WELLMED, 1.35,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40796,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,WELLMED,WELLMED, 32.25,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40797,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,WELLMED,WELLMED, 1.35,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40798,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,WELLMED,WELLMED, 1.94,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40799,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,WELLMED,WELLMED, 43.43,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40800,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,WELLMED,WELLMED, 2.58,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40801,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,WELLMED,WELLMED, 2.58,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40802,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,WELLMED,WELLMED, 79.09,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40803,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,WELLMED,WELLMED, 2.58,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40804,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,WELLMED,WELLMED, 77.40,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40805,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,WELLMED,WELLMED, 24.94,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40806,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,WELLMED,WELLMED, 24.94,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40807,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,WELLMED,WELLMED, 142.83,,OUTPAT REV HCPCS COMBO 1, 212.89,OTHER, 142.83, 325.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40808,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,WELLMED,WELLMED, 52.37,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40809,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,WELLMED,WELLMED, 32.25,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40810,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,WELLMED,WELLMED, 423.39,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40811,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,WELLMED,WELLMED, 308.33,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40812,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,WELLMED,WELLMED, 3.87,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40813,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,WELLMED,WELLMED, 2.58,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40814,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,WELLMED,WELLMED, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40815,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,WELLMED,WELLMED, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40816,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,WELLMED,WELLMED, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40817,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,WELLMED,WELLMED, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40818,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,WELLMED,WELLMED, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40819,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,WELLMED,WELLMED, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40820,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,WELLMED,WELLMED, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40821,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,WELLMED,WELLMED, 2.58,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40822,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,WELLMED,WELLMED, 43.43,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40823,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,WELLMED,WELLMED, 43.86,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40824,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,WELLMED,WELLMED, 30.89,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40825,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,WELLMED,WELLMED, 30.89,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40826,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,WELLMED,WELLMED, 32.25,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40827,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,WELLMED,WELLMED, 59.16,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40828,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,WELLMED,WELLMED, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40829,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,WELLMED,WELLMED, 6.45,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40830,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,WELLMED,WELLMED, 6.45,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40831,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,WELLMED,WELLMED, 6.45,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40832,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,WELLMED,WELLMED, 7.74,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40833,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,WELLMED,WELLMED, 10.32,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40834,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,WELLMED,WELLMED, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40835,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,WELLMED,WELLMED, 12.26,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40836,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,WELLMED,WELLMED, 12.26,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40837,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,WELLMED,WELLMED, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40838,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,WELLMED,WELLMED, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40839,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,WELLMED,WELLMED, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40840,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,WELLMED,WELLMED, 12.90,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40841,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,WELLMED,WELLMED, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40842,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,WELLMED,WELLMED, 1.29,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40843,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,WELLMED,WELLMED, 19.99,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40844,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,WELLMED,WELLMED, 4.30,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40845,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,WELLMED,WELLMED, 1.35,,OUTPAT REV HCPCS COMBO 1, 2.02,OTHER, 1.35, 3.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40846,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,WELLMED,WELLMED, 215.43,,OUTPAT REV HCPCS COMBO 1, 321.10,OTHER, 215.43, 490.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40847,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,WELLMED,WELLMED, 245.96,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40848,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40849,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40850,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40851,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40852,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40853,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40854,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40855,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,WELLMED,WELLMED, 14.63,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40856,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,WELLMED,WELLMED, 65.44,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40857,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,WELLMED,WELLMED, 61.34,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40858,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,WELLMED,WELLMED, 40.07,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40859,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,WELLMED,WELLMED, 36.78,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40860,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,WELLMED,WELLMED, 111.92,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40861,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,WELLMED,WELLMED, 3270.45,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40862,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,WELLMED,WELLMED, 19.44,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40863,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,WELLMED,WELLMED, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40864,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,WELLMED,WELLMED, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40865,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,WELLMED,WELLMED, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40866,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,WELLMED,WELLMED, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40867,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,WELLMED,WELLMED, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40868,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,WELLMED,WELLMED, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40869,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,WELLMED,WELLMED, 1032.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40870,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,WELLMED,WELLMED, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40871,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,WELLMED,WELLMED, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40872,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,WELLMED,WELLMED, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40873,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,WELLMED,WELLMED, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40874,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,WELLMED,WELLMED, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40875,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,WELLMED,WELLMED, 765.40,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40876,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,WELLMED,WELLMED, 602.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40877,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,WELLMED,WELLMED, 602.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40878,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,WELLMED,WELLMED, 602.00,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40879,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40880,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40881,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40882,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,WELLMED,WELLMED, 45.15,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40883,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40884,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,WELLMED,WELLMED, 28.87,,OUTPAT REV HCPCS COMBO 1, 43.03,OTHER, 28.87, 65.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40885,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,WELLMED,WELLMED, 4.30,,OUTPAT REV HCPCS COMBO 1, 6.41,OTHER, 4.30, 9.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40886,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,WELLMED,WELLMED, 2494.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40887,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,WELLMED,WELLMED, 2064.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40888,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,WELLMED,WELLMED, 2064.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40889,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,WELLMED,WELLMED, 2064.00,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40890,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40891,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40892,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40893,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40894,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40895,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40896,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40897,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40898,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40899,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40900,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40901,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40902,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40903,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40904,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40905,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40906,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40907,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40908,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40909,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40910,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40911,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40912,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40913,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40914,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40915,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40916,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,WELLMED,WELLMED,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40917,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,WELLMED,WELLMED, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40918,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40919,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40920,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40921,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40922,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40923,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40924,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40925,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40926,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40927,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40928,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40929,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40930,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40931,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40932,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40933,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40934,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40935,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40936,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 219.79,,OUTPAT REV HCPCS COMBO 1, 271.70,OTHER, 142.76, 477.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40937,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 219.79,,OUTPAT REV HCPCS COMBO 1, 271.70,OTHER, 142.76, 477.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40938,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 124.73,,OUTPAT REV HCPCS COMBO 1, 168.89,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40939,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40940,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 221.79,,OUTPAT REV HCPCS COMBO 1, 273.87,OTHER, 142.76, 481.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40941,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40942,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 163.49,,OUTPAT REV HCPCS COMBO 1, 242.16,OTHER, 155.70, 354.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40943,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40944,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40945,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40946,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40947,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40948,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40949,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40950,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40951,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40952,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40953,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40954,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40955,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40956,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40957,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40958,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40959,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40960,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40961,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40962,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40963,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40964,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40965,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40966,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40967,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40968,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40969,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40970,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40971,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40972,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40973,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40974,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40975,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40976,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40977,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40978,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40979,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40980,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40981,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40982,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40983,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40984,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40985,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40986,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 152.56,,OUTPAT REV HCPCS COMBO 1, 185.53,OTHER, 86.20, 331.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40987,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40988,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40989,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40990,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40991,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40992,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 40993,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 173.26,,OUTPAT REV HCPCS COMBO 1, 278.63,OTHER, 165.01, 383.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40994,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 311.01,,OUTPAT REV HCPCS COMBO 1, 427.61,OTHER, 296.20, 675.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40995,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 188.21,,OUTPAT REV HCPCS COMBO 1, 237.66,OTHER, 143.26, 408.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40996,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 202.99,,OUTPAT REV HCPCS COMBO 1, 253.66,OTHER, 143.26, 440.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40997,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 220.11,,OUTPAT REV HCPCS COMBO 1, 272.17,OTHER, 143.26, 477.75,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40998,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 200.90,,OUTPAT REV HCPCS COMBO 1, 251.39,OTHER, 143.26, 436.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 40999,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41000,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 213.07,,OUTPAT REV HCPCS COMBO 1, 264.56,OTHER, 143.26, 462.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41001,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 215.23,,OUTPAT REV HCPCS COMBO 1, 306.35,OTHER, 204.98, 467.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41002,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41003,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41004,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 241.75,,OUTPAT REV HCPCS COMBO 1, 293.08,OTHER, 132.82, 524.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41005,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 878.56,,OUTPAT REV HCPCS COMBO 1, 1023.77,OTHER, 309.01, 1906.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41006,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41007,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1479.23,,OUTPAT REV HCPCS COMBO 1, 1703.49,OTHER, 435.32, 3210.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41008,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41009,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41010,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41011,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41012,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 152.56,,OUTPAT REV HCPCS COMBO 1, 200.99,OTHER, 145.30, 331.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41013,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41014,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41015,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41016,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41017,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41018,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41019,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41020,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 59.87,,OUTPAT REV HCPCS COMBO 1, 124.43,OTHER, 57.02, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41021,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 55.99,,OUTPAT REV HCPCS COMBO 1, 120.23,OTHER, 53.32, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41022,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 65.24,,OUTPAT REV HCPCS COMBO 1, 130.25,OTHER, 62.14, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41023,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 65.24,,OUTPAT REV HCPCS COMBO 1, 130.25,OTHER, 62.14, 250.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41024,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41025,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41026,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 356.78,,OUTPAT REV HCPCS COMBO 1, 424.57,OTHER, 162.56, 774.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41027,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 273.86,,OUTPAT REV HCPCS COMBO 1, 334.89,OTHER, 162.56, 594.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41028,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 521.41,,OUTPAT REV HCPCS COMBO 1, 675.88,OTHER, 470.23, 1131.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41029,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 426.31,,OUTPAT REV HCPCS COMBO 1, 499.77,OTHER, 162.56, 925.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41030,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 426.31,,OUTPAT REV HCPCS COMBO 1, 499.77,OTHER, 162.56, 925.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41031,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 156.24,,OUTPAT REV HCPCS COMBO 1, 207.69,OTHER, 148.80, 339.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41032,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 156.24,,OUTPAT REV HCPCS COMBO 1, 207.69,OTHER, 148.80, 339.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41033,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 140.63,,OUTPAT REV HCPCS COMBO 1, 176.70,OTHER, 103.34, 305.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41034,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 510.17,,OUTPAT REV HCPCS COMBO 1, 596.69,OTHER, 188.66, 1107.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41035,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 510.17,,OUTPAT REV HCPCS COMBO 1, 596.69,OTHER, 188.66, 1107.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41036,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 887.62,,OUTPAT REV HCPCS COMBO 1, 1089.64,OTHER, 544.52, 1926.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41037,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 15.80,,OUTPAT REV HCPCS COMBO 1, 22.43,OTHER, 15.05, 34.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41038,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 14.02,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41039,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 14.02,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41040,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 14.02,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41041,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 14.02,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41042,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 14.02,,OUTPAT REV HCPCS COMBO 1, 18.10,OTHER, 12.34, 30.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41043,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41044,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 11.29,,OUTPAT REV HCPCS COMBO 1, 16.02,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41045,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 462.39,,OUTPAT REV HCPCS COMBO 1, 579.04,OTHER, 331.58, 1003.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41046,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41047,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41048,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41049,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41050,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41051,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 109.08,,OUTPAT REV HCPCS COMBO 1, 124.21,OTHER, 26.22, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41052,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 109.08,,OUTPAT REV HCPCS COMBO 1, 124.21,OTHER, 26.22, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41053,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41054,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41055,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41056,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41057,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41058,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41059,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41060,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41061,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41062,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41063,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41064,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41065,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 526.55,,OUTPAT REV HCPCS COMBO 1, 718.33,OTHER, 501.48, 1142.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41066,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41067,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41068,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41069,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41070,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41071,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41072,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41073,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41074,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41075,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41076,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41077,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41078,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41079,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41080,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41081,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41082,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41083,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41084,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41085,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41086,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41087,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41088,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41089,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41090,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41091,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 181.93,,OUTPAT REV HCPCS COMBO 1, 242.39,OTHER, 173.27, 394.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41092,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 181.93,,OUTPAT REV HCPCS COMBO 1, 242.39,OTHER, 173.27, 394.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41093,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41094,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 101.59,,OUTPAT REV HCPCS COMBO 1, 199.77,OTHER, 96.75, 377.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41095,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 101.59,,OUTPAT REV HCPCS COMBO 1, 266.50,OTHER, 96.75, 657.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41096,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1552.26,,OUTPAT REV HCPCS COMBO 1, 2146.91,OTHER, 1478.34, 3369.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41097,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1552.26,,OUTPAT REV HCPCS COMBO 1, 2146.91,OTHER, 1478.34, 3369.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41098,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 506.97,,OUTPAT REV HCPCS COMBO 1, 719.65,OTHER, 482.83, 1100.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41099,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 906.86,,OUTPAT REV HCPCS COMBO 1, 1287.31,OTHER, 863.68, 1968.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41100,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 204.94,,OUTPAT REV HCPCS COMBO 1, 290.91,OTHER, 195.18, 444.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41101,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41102,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 117.90,,OUTPAT REV HCPCS COMBO 1, 162.43,OTHER, 112.28, 255.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41103,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 102.08,,OUTPAT REV HCPCS COMBO 1, 145.32,OTHER, 97.21, 221.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41104,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 65.20,,OUTPAT REV HCPCS COMBO 1, 116.13,OTHER, 62.09, 191.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41105,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 53.73,,OUTPAT REV HCPCS COMBO 1, 76.24,OTHER, 51.17, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41106,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 96.20,,OUTPAT REV HCPCS COMBO 1, 124.60,OTHER, 86.34, 208.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41107,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41108,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.83,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41109,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41110,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 61.86,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41111,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41112,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 118.86,,OUTPAT REV HCPCS COMBO 1, 161.46,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41113,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41114,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.83,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41115,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41116,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 128.57,,OUTPAT REV HCPCS COMBO 1, 171.96,OTHER, 122.45, 279.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41117,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41118,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 99.10,,OUTPAT REV HCPCS COMBO 1, 127.74,OTHER, 86.34, 215.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41119,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41120,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 144.87,,OUTPAT REV HCPCS COMBO 1, 189.58,OTHER, 137.97, 314.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41121,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41122,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 89.09,,OUTPAT REV HCPCS COMBO 1, 116.92,OTHER, 84.85, 193.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41123,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41124,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 246.53,,OUTPAT REV HCPCS COMBO 1, 299.54,OTHER, 138.19, 535.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41125,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41126,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 173.95,,OUTPAT REV HCPCS COMBO 1, 221.04,OTHER, 138.19, 377.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41127,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41128,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 133.64,,OUTPAT REV HCPCS COMBO 1, 177.44,OTHER, 127.28, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41129,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41130,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 46.83,,OUTPAT REV HCPCS COMBO 1, 71.21,OTHER, 44.60, 101.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41131,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41132,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 159.96,,OUTPAT REV HCPCS COMBO 1, 193.56,OTHER, 86.34, 347.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41133,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41134,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 187.64,,OUTPAT REV HCPCS COMBO 1, 223.50,OTHER, 86.34, 407.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41135,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1322.06,,OUTPAT REV HCPCS COMBO 1, 1313.91,OTHER, 283.82, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41136,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 982.68,,OUTPAT REV HCPCS COMBO 1, 1313.91,OTHER, 283.82, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41137,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41138,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41139,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1010.73,,OUTPAT REV HCPCS COMBO 1, 1196.04,OTHER, 432.18, 2193.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41140,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1010.73,,OUTPAT REV HCPCS COMBO 1, 1196.04,OTHER, 432.18, 2193.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41141,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41142,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41143,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1322.06,,OUTPAT REV HCPCS COMBO 1, 1545.39,OTHER, 485.27, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41144,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1322.06,,OUTPAT REV HCPCS COMBO 1, 1545.39,OTHER, 485.27, 2869.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41145,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41146,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41147,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 820.71,,OUTPAT REV HCPCS COMBO 1, 955.20,OTHER, 283.82, 1781.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41148,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41149,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 544.08,,OUTPAT REV HCPCS COMBO 1, 691.35,OTHER, 432.18, 1180.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41150,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41151,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 713.37,,OUTPAT REV HCPCS COMBO 1, 887.08,OTHER, 485.27, 1548.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41152,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41153,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 770.71,,OUTPAT REV HCPCS COMBO 1, 901.22,OTHER, 283.82, 1673.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41154,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 770.88,,OUTPAT REV HCPCS COMBO 1, 901.22,OTHER, 283.82, 1673.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41155,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41156,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41157,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 881.18,,OUTPAT REV HCPCS COMBO 1, 1055.93,OTHER, 432.18, 1912.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41158,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1109.33,,OUTPAT REV HCPCS COMBO 1, 1302.68,OTHER, 432.18, 2407.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41159,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41160,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41161,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 367.52,,OUTPAT REV HCPCS COMBO 1, 513.03,OTHER, 350.02, 797.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41162,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41163,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1130.81,,OUTPAT REV HCPCS COMBO 1, 1290.59,OTHER, 283.82, 2454.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41164,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41165,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1176.02,,OUTPAT REV HCPCS COMBO 1, 1374.81,OTHER, 432.18, 2552.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41166,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41167,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1063.69,,OUTPAT REV HCPCS COMBO 1, 1265.96,OTHER, 485.27, 2308.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41168,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41169,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 885.96,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41170,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 885.96,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41171,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 885.96,,OUTPAT REV HCPCS COMBO 1, 1076.14,OTHER, 495.38, 1923.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41172,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41173,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41174,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41175,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1065.95,,OUTPAT REV HCPCS COMBO 1, 1270.81,OTHER, 495.38, 2313.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41176,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41177,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1383.25,,OUTPAT REV HCPCS COMBO 1, 1681.52,OTHER, 779.04, 3002.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41178,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41179,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1020.57,,OUTPAT REV HCPCS COMBO 1, 1224.87,OTHER, 508.57, 2215.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41180,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41181,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1088.57,,OUTPAT REV HCPCS COMBO 1, 1324.21,OTHER, 616.91, 2362.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41182,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41183,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1245.91,,OUTPAT REV HCPCS COMBO 1, 1532.99,OTHER, 779.04, 2704.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41184,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41185,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1028.63,,OUTPAT REV HCPCS COMBO 1, 1233.59,OTHER, 508.57, 2232.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41186,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41187,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1025.81,,OUTPAT REV HCPCS COMBO 1, 1256.33,OTHER, 616.91, 2226.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41188,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41189,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1179.43,,OUTPAT REV HCPCS COMBO 1, 1461.09,OTHER, 779.04, 2560.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41190,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41191,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1195.13,,OUTPAT REV HCPCS COMBO 1, 1413.66,OTHER, 508.57, 2594.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41192,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41193,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1845.24,,OUTPAT REV HCPCS COMBO 1, 2181.19,OTHER, 779.04, 4005.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41194,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1845.24,,OUTPAT REV HCPCS COMBO 1, 2181.19,OTHER, 779.04, 4005.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41195,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41196,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41197,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.83,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41198,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.83,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41199,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.83,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41200,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.83,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41201,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41202,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41203,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41204,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41205,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.83,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41206,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41207,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.83,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41208,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.83,,OUTPAT REV HCPCS COMBO 1, 63.51,OTHER, 36.98, 90.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41209,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41210,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41211,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 204.80,,OUTPAT REV HCPCS COMBO 1, 242.05,OTHER, 86.34, 444.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41212,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 206.15,,OUTPAT REV HCPCS COMBO 1, 243.52,OTHER, 86.34, 447.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41213,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41214,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41215,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 167.57,,OUTPAT REV HCPCS COMBO 1, 214.14,OTHER, 138.19, 363.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41216,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 191.51,,OUTPAT REV HCPCS COMBO 1, 240.03,OTHER, 138.19, 415.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41217,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41218,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41219,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 199.68,,OUTPAT REV HCPCS COMBO 1, 248.87,OTHER, 138.19, 433.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41220,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41221,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 133.64,,OUTPAT REV HCPCS COMBO 1, 165.10,OTHER, 86.34, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41222,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41223,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.83,,OUTPAT REV HCPCS COMBO 1, 62.55,OTHER, 36.98, 86.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41224,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41225,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1057.59,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41226,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1057.59,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41227,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1057.59,,OUTPAT REV HCPCS COMBO 1, 1211.40,OTHER, 283.82, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41228,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41229,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41230,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1057.59,,OUTPAT REV HCPCS COMBO 1, 1356.87,OTHER, 432.18, 2737.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41231,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1261.27,,OUTPAT REV HCPCS COMBO 1, 1356.87,OTHER, 432.18, 2737.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41232,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41233,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1573.41,,OUTPAT REV HCPCS COMBO 1, 1817.25,OTHER, 485.27, 3415.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41234,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41235,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1057.59,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41236,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1057.59,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41237,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1057.59,,OUTPAT REV HCPCS COMBO 1, 1171.85,OTHER, 117.71, 2295.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41238,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41239,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41240,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41241,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2248.48,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41242,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1515.09,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41243,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1515.09,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41244,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1515.09,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41245,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1515.09,,OUTPAT REV HCPCS COMBO 1, 1915.21,OTHER, 495.38, 4880.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41246,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41247,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41248,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41249,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41250,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 571.60,,OUTPAT REV HCPCS COMBO 1, 1310.99,OTHER, 544.38, 2768.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41251,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1275.49,,OUTPAT REV HCPCS COMBO 1, 1310.99,OTHER, 544.38, 2768.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41252,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41253,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41254,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 137.26,,OUTPAT REV HCPCS COMBO 1, 169.01,OTHER, 86.34, 297.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41255,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 137.26,,OUTPAT REV HCPCS COMBO 1, 169.01,OTHER, 86.34, 297.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41256,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41257,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41258,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 198.56,,OUTPAT REV HCPCS COMBO 1, 247.65,OTHER, 138.19, 430.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41259,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41260,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 293.75,,OUTPAT REV HCPCS COMBO 1, 350.60,OTHER, 138.19, 637.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41261,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41262,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 323.36,,OUTPAT REV HCPCS COMBO 1, 382.63,OTHER, 138.19, 701.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41263,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41264,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 240.95,,OUTPAT REV HCPCS COMBO 1, 293.50,OTHER, 138.19, 522.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41265,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41266,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 215.39,,OUTPAT REV HCPCS COMBO 1, 265.86,OTHER, 138.19, 467.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41267,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41268,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 118.86,,OUTPAT REV HCPCS COMBO 1, 161.46,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41269,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41270,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 112.88,,OUTPAT REV HCPCS COMBO 1, 142.64,OTHER, 86.34, 245.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41271,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41272,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.83,,OUTPAT REV HCPCS COMBO 1, 63.06,OTHER, 36.98, 88.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41273,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 118.86,,OUTPAT REV HCPCS COMBO 1, 163.44,OTHER, 113.20, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41274,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41275,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 209.27,,OUTPAT REV HCPCS COMBO 1, 259.24,OTHER, 138.19, 454.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41276,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41277,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 123.90,,OUTPAT REV HCPCS COMBO 1, 166.91,OTHER, 118.00, 268.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41278,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41279,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 345.97,,OUTPAT REV HCPCS COMBO 1, 407.08,OTHER, 138.19, 750.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41280,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41281,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1286.87,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41282,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1286.87,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41283,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1286.87,,OUTPAT REV HCPCS COMBO 1, 1459.38,OTHER, 283.82, 2793.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41284,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41285,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41286,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41287,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 507.94,,OUTPAT REV HCPCS COMBO 1, 664.89,OTHER, 483.75, 1102.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41288,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41289,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1462.30,,OUTPAT REV HCPCS COMBO 1, 1649.11,OTHER, 283.82, 3173.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41290,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1462.30,,OUTPAT REV HCPCS COMBO 1, 1649.11,OTHER, 283.82, 3173.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41291,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41292,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41293,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1444.80,,OUTPAT REV HCPCS COMBO 1, 1665.51,OTHER, 432.18, 3136.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41294,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41295,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1268.20,,OUTPAT REV HCPCS COMBO 1, 1439.18,OTHER, 283.82, 2752.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41296,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41297,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1432.85,,OUTPAT REV HCPCS COMBO 1, 1652.58,OTHER, 432.18, 3110.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41298,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41299,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1354.50,,OUTPAT REV HCPCS COMBO 1, 1580.48,OTHER, 485.27, 2940.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41300,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41301,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1471.24,,OUTPAT REV HCPCS COMBO 1, 1712.29,OTHER, 508.57, 3193.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41302,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41303,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1639.97,,OUTPAT REV HCPCS COMBO 1, 1894.78,OTHER, 508.57, 3559.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41304,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41305,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1439.47,,OUTPAT REV HCPCS COMBO 1, 1677.93,OTHER, 508.57, 3124.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41306,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41307,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1788.48,,OUTPAT REV HCPCS COMBO 1, 2119.80,OTHER, 779.04, 3881.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41308,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41309,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2176.58,,OUTPAT REV HCPCS COMBO 1, 2539.54,OTHER, 779.04, 4724.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41310,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41311,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2038.50,,OUTPAT REV HCPCS COMBO 1, 2390.20,OTHER, 779.04, 4424.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41312,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41313,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41314,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41315,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41316,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 188.54,,OUTPAT REV HCPCS COMBO 1, 236.81,OTHER, 138.19, 409.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41317,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41318,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 148.83,,OUTPAT REV HCPCS COMBO 1, 193.87,OTHER, 138.19, 323.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41319,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41320,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1103.60,,OUTPAT REV HCPCS COMBO 1, 1261.16,OTHER, 283.82, 2395.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41321,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1103.60,,OUTPAT REV HCPCS COMBO 1, 1261.16,OTHER, 283.82, 2395.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41322,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41323,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41324,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1066.26,,OUTPAT REV HCPCS COMBO 1, 1256.10,OTHER, 432.18, 2314.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41325,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41326,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 720.37,,OUTPAT REV HCPCS COMBO 1, 894.65,OTHER, 485.27, 1563.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41327,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41328,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1507.52,,OUTPAT REV HCPCS COMBO 1, 1751.53,OTHER, 508.57, 3272.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41329,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41330,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2259.62,,OUTPAT REV HCPCS COMBO 1, 2629.35,OTHER, 779.04, 4904.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41331,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41332,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41333,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41334,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1281.83,OTHER, 860.00, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41335,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41336,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41337,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41338,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 132.80,,OUTPAT REV HCPCS COMBO 1, 164.19,OTHER, 86.34, 288.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41339,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41340,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 188.43,,OUTPAT REV HCPCS COMBO 1, 224.35,OTHER, 86.34, 408.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41341,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41342,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 173.97,,OUTPAT REV HCPCS COMBO 1, 208.71,OTHER, 86.34, 377.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41343,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 173.97,,OUTPAT REV HCPCS COMBO 1, 208.71,OTHER, 86.34, 377.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41344,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 180.44,,OUTPAT REV HCPCS COMBO 1, 215.71,OTHER, 86.34, 391.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41345,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41346,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41347,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41348,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 118.86,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41349,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 118.86,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41350,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 118.86,,OUTPAT REV HCPCS COMBO 1, 149.11,OTHER, 86.34, 257.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41351,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41352,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41353,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41354,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 143.58,,OUTPAT REV HCPCS COMBO 1, 175.84,OTHER, 86.34, 311.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41355,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 137.31,,OUTPAT REV HCPCS COMBO 1, 169.06,OTHER, 86.34, 298.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41356,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 137.31,,OUTPAT REV HCPCS COMBO 1, 169.06,OTHER, 86.34, 298.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41357,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41358,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41359,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41360,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 186.92,,OUTPAT REV HCPCS COMBO 1, 235.06,OTHER, 138.19, 405.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41361,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 186.92,,OUTPAT REV HCPCS COMBO 1, 235.06,OTHER, 138.19, 405.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41362,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 191.82,,OUTPAT REV HCPCS COMBO 1, 240.36,OTHER, 138.19, 416.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41363,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41364,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41365,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41366,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 184.13,,OUTPAT REV HCPCS COMBO 1, 219.70,OTHER, 86.34, 399.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41367,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 179.28,,OUTPAT REV HCPCS COMBO 1, 214.45,OTHER, 86.34, 389.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41368,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 179.28,,OUTPAT REV HCPCS COMBO 1, 214.45,OTHER, 86.34, 389.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41369,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41370,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41371,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41372,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 171.98,,OUTPAT REV HCPCS COMBO 1, 206.56,OTHER, 86.34, 373.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41373,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 176.83,,OUTPAT REV HCPCS COMBO 1, 211.81,OTHER, 86.34, 383.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41374,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 171.98,,OUTPAT REV HCPCS COMBO 1, 206.56,OTHER, 86.34, 373.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41375,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41376,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41377,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41378,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 193.69,,OUTPAT REV HCPCS COMBO 1, 230.04,OTHER, 86.34, 420.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41379,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 187.64,,OUTPAT REV HCPCS COMBO 1, 223.50,OTHER, 86.34, 407.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41380,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41381,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41382,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41383,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 194.42,,OUTPAT REV HCPCS COMBO 1, 230.83,OTHER, 86.34, 421.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41384,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 194.42,,OUTPAT REV HCPCS COMBO 1, 230.83,OTHER, 86.34, 421.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41385,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 200.47,,OUTPAT REV HCPCS COMBO 1, 237.37,OTHER, 86.34, 435.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41386,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41387,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41388,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41389,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 61.86,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41390,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 85.79,,OUTPAT REV HCPCS COMBO 1, 125.68,OTHER, 81.70, 186.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41391,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 61.86,,OUTPAT REV HCPCS COMBO 1, 99.80,OTHER, 58.91, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41392,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41393,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41394,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41395,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 178.61,,OUTPAT REV HCPCS COMBO 1, 213.73,OTHER, 86.34, 387.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41396,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 173.06,,OUTPAT REV HCPCS COMBO 1, 207.73,OTHER, 86.34, 375.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41397,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 173.07,,OUTPAT REV HCPCS COMBO 1, 207.74,OTHER, 86.34, 375.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41398,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41399,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41400,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41401,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 201.22,,OUTPAT REV HCPCS COMBO 1, 238.18,OTHER, 86.34, 436.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41402,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 206.08,,OUTPAT REV HCPCS COMBO 1, 243.44,OTHER, 86.34, 447.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41403,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 201.22,,OUTPAT REV HCPCS COMBO 1, 238.18,OTHER, 86.34, 436.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41404,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41405,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41406,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41407,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 190.08,,OUTPAT REV HCPCS COMBO 1, 238.48,OTHER, 138.19, 412.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41408,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 184.03,,OUTPAT REV HCPCS COMBO 1, 231.94,OTHER, 138.19, 399.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41409,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 184.03,,OUTPAT REV HCPCS COMBO 1, 231.94,OTHER, 138.19, 399.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41410,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41411,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41412,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41413,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 184.74,,OUTPAT REV HCPCS COMBO 1, 220.36,OTHER, 86.34, 400.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41414,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 184.79,,OUTPAT REV HCPCS COMBO 1, 220.42,OTHER, 86.34, 401.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41415,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 189.65,,OUTPAT REV HCPCS COMBO 1, 225.67,OTHER, 86.34, 411.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41416,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41417,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41418,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41419,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 153.92,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41420,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 142.52,,OUTPAT REV HCPCS COMBO 1, 174.69,OTHER, 86.34, 309.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41421,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 137.66,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41422,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 137.66,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41423,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 137.66,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41424,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 137.66,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41425,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 137.66,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41426,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 137.66,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41427,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 137.66,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41428,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 137.66,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41429,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 137.66,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41430,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 137.66,,OUTPAT REV HCPCS COMBO 1, 169.45,OTHER, 86.34, 298.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41431,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 137.66,,OUTPAT REV HCPCS COMBO 1, 172.96,OTHER, 86.34, 334.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41432,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41433,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41434,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41435,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41436,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41437,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41438,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41439,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41440,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41441,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41442,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41443,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41444,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41445,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 854.09,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41446,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 918.59,,OUTPAT REV HCPCS COMBO 1, 1061.06,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41447,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 918.59,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41448,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 918.59,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41449,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 918.59,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41450,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 918.59,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41451,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 918.59,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41452,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 302.05,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41453,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 302.05,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41454,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 918.59,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41455,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 918.59,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41456,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 302.05,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41457,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 918.59,,OUTPAT REV HCPCS COMBO 1, 860.58,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41458,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 918.59,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41459,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 854.09,,OUTPAT REV HCPCS COMBO 1, 955.84,OTHER, 283.82, 1993.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41460,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41461,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41462,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41463,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41464,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41465,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41466,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41467,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41468,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41469,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41470,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41471,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41472,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41473,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41474,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1277.29,,OUTPAT REV HCPCS COMBO 1, 1484.34,OTHER, 432.18, 2772.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41475,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1277.29,,OUTPAT REV HCPCS COMBO 1, 1484.34,OTHER, 432.18, 2772.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41476,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41477,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41478,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41479,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 609.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41480,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 609.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41481,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41482,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41483,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 864.01,,OUTPAT REV HCPCS COMBO 1, 1055.55,OTHER, 508.57, 1875.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41484,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41485,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1490.06,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41486,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1490.06,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41487,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1490.06,,OUTPAT REV HCPCS COMBO 1, 1797.05,OTHER, 779.04, 3234.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41488,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41489,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41490,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41491,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41492,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41493,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41494,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41495,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41496,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41497,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41498,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41499,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41500,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41501,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41502,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41503,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41504,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41505,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41506,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1519.15,,OUTPAT REV HCPCS COMBO 1, 1764.11,OTHER, 508.57, 3297.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41507,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41508,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41509,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41510,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41511,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41512,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41513,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41514,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41515,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41516,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41517,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41518,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41519,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41520,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41521,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41522,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41523,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1169.50,,OUTPAT REV HCPCS COMBO 1, 1450.34,OTHER, 779.04, 2538.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41524,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1169.50,,OUTPAT REV HCPCS COMBO 1, 1450.34,OTHER, 779.04, 2538.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41525,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41526,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41527,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41528,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41529,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41530,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41531,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 162.67,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41532,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 162.67,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41533,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 162.67,,OUTPAT REV HCPCS COMBO 1, 196.99,OTHER, 88.46, 353.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41534,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41535,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41536,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41537,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.11,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41538,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.11,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41539,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.11,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41540,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.11,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41541,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.11,,OUTPAT REV HCPCS COMBO 1, 190.98,OTHER, 88.46, 341.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41542,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41543,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41544,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41545,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41546,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 205.51,,OUTPAT REV HCPCS COMBO 1, 234.40,OTHER, 146.51, 446.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41547,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 163.43,,OUTPAT REV HCPCS COMBO 1, 234.40,OTHER, 146.51, 446.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41548,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41549,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41550,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 168.20,,OUTPAT REV HCPCS COMBO 1, 202.98,OTHER, 88.46, 365.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41551,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 168.20,,OUTPAT REV HCPCS COMBO 1, 202.98,OTHER, 88.46, 365.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41552,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 173.06,,OUTPAT REV HCPCS COMBO 1, 208.23,OTHER, 88.46, 375.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41553,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41554,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41555,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41556,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 175.83,,OUTPAT REV HCPCS COMBO 1, 210.73,OTHER, 86.34, 381.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41557,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 170.29,,OUTPAT REV HCPCS COMBO 1, 204.73,OTHER, 86.34, 369.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41558,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 170.29,,OUTPAT REV HCPCS COMBO 1, 204.73,OTHER, 86.34, 369.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41559,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41560,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41561,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41562,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 218.45,,OUTPAT REV HCPCS COMBO 1, 269.16,OTHER, 138.19, 474.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41563,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 223.30,,OUTPAT REV HCPCS COMBO 1, 274.41,OTHER, 138.19, 484.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41564,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 218.45,,OUTPAT REV HCPCS COMBO 1, 269.16,OTHER, 138.19, 474.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41565,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41566,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41567,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41568,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 341.33,,OUTPAT REV HCPCS COMBO 1, 402.07,OTHER, 138.19, 740.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41569,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 335.13,,OUTPAT REV HCPCS COMBO 1, 395.36,OTHER, 138.19, 727.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41570,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 335.13,,OUTPAT REV HCPCS COMBO 1, 395.36,OTHER, 138.19, 727.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41571,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41572,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41573,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41574,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 122.80,,OUTPAT REV HCPCS COMBO 1, 153.37,OTHER, 86.34, 266.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41575,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41576,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 205.74,,OUTPAT REV HCPCS COMBO 1, 243.07,OTHER, 86.34, 446.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41577,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 200.89,,OUTPAT REV HCPCS COMBO 1, 237.82,OTHER, 86.34, 436.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41578,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 200.89,,OUTPAT REV HCPCS COMBO 1, 237.82,OTHER, 86.34, 436.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41579,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41580,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41581,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41582,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.83,,OUTPAT REV HCPCS COMBO 1, 74.90,OTHER, 36.98, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41583,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.83,,OUTPAT REV HCPCS COMBO 1, 74.90,OTHER, 36.98, 138.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41584,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 77.66,,OUTPAT REV HCPCS COMBO 1, 116.89,OTHER, 73.96, 168.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41585,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41586,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41587,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41588,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 172.02,,OUTPAT REV HCPCS COMBO 1, 218.95,OTHER, 138.19, 373.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41589,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 172.02,,OUTPAT REV HCPCS COMBO 1, 218.95,OTHER, 138.19, 373.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41590,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 177.89,,OUTPAT REV HCPCS COMBO 1, 225.30,OTHER, 138.19, 386.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41591,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41592,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41593,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41594,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 194.60,,OUTPAT REV HCPCS COMBO 1, 243.37,OTHER, 138.19, 422.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41595,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 188.49,,OUTPAT REV HCPCS COMBO 1, 236.76,OTHER, 138.19, 409.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41596,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 188.49,,OUTPAT REV HCPCS COMBO 1, 236.76,OTHER, 138.19, 409.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41597,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41598,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41599,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41600,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 153.49,,OUTPAT REV HCPCS COMBO 1, 186.56,OTHER, 86.34, 333.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41601,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 153.49,,OUTPAT REV HCPCS COMBO 1, 186.56,OTHER, 86.34, 333.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41602,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41603,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41604,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 212.32,,OUTPAT REV HCPCS COMBO 1, 250.19,OTHER, 86.34, 460.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41605,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 207.38,,OUTPAT REV HCPCS COMBO 1, 244.84,OTHER, 86.34, 450.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41606,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 207.47,,OUTPAT REV HCPCS COMBO 1, 244.94,OTHER, 86.34, 450.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41607,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41608,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41609,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41610,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 105.20,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41611,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 105.20,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41612,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 105.20,,OUTPAT REV HCPCS COMBO 1, 134.33,OTHER, 86.34, 228.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41613,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41614,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41615,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41616,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41617,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41618,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41619,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41620,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41621,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41622,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41623,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41624,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 146.74,,OUTPAT REV HCPCS COMBO 1, 179.26,OTHER, 86.34, 318.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41625,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41626,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 140.48,,OUTPAT REV HCPCS COMBO 1, 172.49,OTHER, 86.34, 304.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41627,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41628,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41629,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41630,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41631,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41632,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41633,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41634,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41635,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41636,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41637,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41638,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41639,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41640,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41641,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1040.71,,OUTPAT REV HCPCS COMBO 1, 1193.14,OTHER, 283.82, 2258.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41642,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41643,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41644,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41645,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41646,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41647,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41648,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41649,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41650,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41651,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1034.82,,OUTPAT REV HCPCS COMBO 1, 1186.77,OTHER, 283.82, 2246.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41652,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41653,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41654,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41655,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41656,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41657,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41658,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41659,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41660,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41661,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41662,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41663,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41664,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41665,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41666,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1231.69,,OUTPAT REV HCPCS COMBO 1, 1435.02,OTHER, 432.18, 2673.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41667,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1225.57,,OUTPAT REV HCPCS COMBO 1, 1428.39,OTHER, 432.18, 2660.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41668,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1225.57,,OUTPAT REV HCPCS COMBO 1, 1428.39,OTHER, 432.18, 2660.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41669,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41670,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41671,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41672,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 609.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41673,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 609.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41674,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 609.07,,OUTPAT REV HCPCS COMBO 1, 774.28,OTHER, 485.27, 1322.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41675,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41676,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41677,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41678,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 627.13,,OUTPAT REV HCPCS COMBO 1, 796.22,OTHER, 495.38, 1361.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41679,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 627.13,,OUTPAT REV HCPCS COMBO 1, 796.22,OTHER, 495.38, 1361.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41680,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41681,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41682,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1335.96,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41683,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1335.96,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41684,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1335.96,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41685,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1335.96,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41686,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1335.96,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41687,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1335.96,,OUTPAT REV HCPCS COMBO 1, 1565.98,OTHER, 508.57, 2899.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41688,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41689,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41690,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41691,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41692,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41693,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41694,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1634.60,,OUTPAT REV HCPCS COMBO 1, 1953.37,OTHER, 779.04, 3547.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41695,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1634.60,,OUTPAT REV HCPCS COMBO 1, 1953.37,OTHER, 779.04, 3547.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41696,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41697,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41698,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41699,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41700,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41701,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41702,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41703,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41704,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41705,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41706,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41707,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1423.91,,OUTPAT REV HCPCS COMBO 1, 1661.10,OTHER, 508.57, 3090.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41708,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41709,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41710,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41711,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41712,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41713,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41714,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41715,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41716,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41717,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41718,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2078.21,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41719,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2078.21,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41720,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2078.21,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41721,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2078.21,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41722,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2078.21,,OUTPAT REV HCPCS COMBO 1, 2433.15,OTHER, 779.04, 4510.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41723,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41724,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41725,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41726,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41727,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41728,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1227.35,OTHER, 786.90, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41729,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1038.45,,OUTPAT REV HCPCS COMBO 1, 1323.48,OTHER, 786.90, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41730,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1038.45,,OUTPAT REV HCPCS COMBO 1, 1474.10,OTHER, 989.00, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41731,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 826.25,,OUTPAT REV HCPCS COMBO 1, 1227.35,OTHER, 786.90, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41732,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 826.25,,OUTPAT REV HCPCS COMBO 1, 1323.48,OTHER, 786.90, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41733,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41734,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41735,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41736,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41737,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41738,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 74.95,,OUTPAT REV HCPCS COMBO 1, 102.58,OTHER, 71.38, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41739,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 74.95,,OUTPAT REV HCPCS COMBO 1, 102.58,OTHER, 71.38, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41740,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41741,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41742,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.83,,OUTPAT REV HCPCS COMBO 1, 83.13,OTHER, 36.98, 172.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41743,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41744,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 267.70,,OUTPAT REV HCPCS COMBO 1, 322.43,OTHER, 138.19, 581.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41745,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 267.70,,OUTPAT REV HCPCS COMBO 1, 322.43,OTHER, 138.19, 581.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41746,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41747,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41748,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1182.07,,OUTPAT REV HCPCS COMBO 1, 1346.03,OTHER, 283.82, 2565.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41749,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41750,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1332.66,,OUTPAT REV HCPCS COMBO 1, 1544.22,OTHER, 432.18, 2892.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41751,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41752,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1504.95,,OUTPAT REV HCPCS COMBO 1, 1743.20,OTHER, 485.27, 3266.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41753,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41754,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2699.98,,OUTPAT REV HCPCS COMBO 1, 3113.75,OTHER, 813.20, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41755,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41756,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1502.96,,OUTPAT REV HCPCS COMBO 1, 1743.46,OTHER, 495.38, 3262.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41757,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41758,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2351.96,,OUTPAT REV HCPCS COMBO 1, 2609.45,OTHER, 276.02, 5105.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41759,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2351.96,,OUTPAT REV HCPCS COMBO 1, 2609.45,OTHER, 276.02, 5105.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41760,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41761,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41762,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2699.98,,OUTPAT REV HCPCS COMBO 1, 3021.78,OTHER, 426.91, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41763,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2699.98,,OUTPAT REV HCPCS COMBO 1, 3021.78,OTHER, 426.91, 5860.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41764,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41765,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41766,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 3025.14,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41767,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 3025.14,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41768,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 3025.14,,OUTPAT REV HCPCS COMBO 1, 3385.13,OTHER, 475.94, 6566.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41769,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41770,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41771,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41772,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1450.33,,OUTPAT REV HCPCS COMBO 1, 1689.68,OTHER, 508.57, 3148.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41773,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1450.33,,OUTPAT REV HCPCS COMBO 1, 1689.68,OTHER, 508.57, 3148.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41774,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41775,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41776,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1527.06,,OUTPAT REV HCPCS COMBO 1, 1837.06,OTHER, 779.04, 3314.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41777,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41778,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1128.75,,OUTPAT REV HCPCS COMBO 1, 2098.35,OTHER, 1075.00, 3967.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41779,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1827.67,,OUTPAT REV HCPCS COMBO 1, 2098.35,OTHER, 1075.00, 3967.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41780,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41781,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41782,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41783,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 315.15,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41784,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 315.15,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41785,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 315.15,,OUTPAT REV HCPCS COMBO 1, 371.17,OTHER, 127.36, 684.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41786,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41787,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41788,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 495.99,,OUTPAT REV HCPCS COMBO 1, 704.06,OTHER, 472.37, 1076.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41789,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41790,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 174.46,,OUTPAT REV HCPCS COMBO 1, 248.14,OTHER, 166.15, 378.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41791,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41792,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 342.50,,OUTPAT REV HCPCS COMBO 1, 429.88,OTHER, 249.71, 743.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41793,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41794,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1273.76,,OUTPAT REV HCPCS COMBO 1, 1495.57,OTHER, 495.38, 2764.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41795,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1273.76,,OUTPAT REV HCPCS COMBO 1, 1495.57,OTHER, 495.38, 2764.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41796,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41797,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41798,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 158.03,,OUTPAT REV HCPCS COMBO 1, 224.32,OTHER, 150.50, 343.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41799,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41800,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 325.30,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41801,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 325.30,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41802,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 325.30,,OUTPAT REV HCPCS COMBO 1, 385.53,OTHER, 141.55, 706.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41803,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41804,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41805,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41806,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 244.97,,OUTPAT REV HCPCS COMBO 1, 286.59,OTHER, 90.89, 531.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41807,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41808,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 230.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41809,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 230.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41810,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 230.87,,OUTPAT REV HCPCS COMBO 1, 281.44,OTHER, 133.37, 501.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41811,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 237.04,,OUTPAT REV HCPCS COMBO 1, 288.12,OTHER, 133.37, 514.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41812,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41813,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41814,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41815,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41816,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 434.37,,OUTPAT REV HCPCS COMBO 1, 503.49,OTHER, 141.55, 942.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41817,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41818,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 396.69,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41819,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 396.69,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41820,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 396.69,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41821,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 396.69,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41822,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 396.69,,OUTPAT REV HCPCS COMBO 1, 462.74,OTHER, 141.55, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41823,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41824,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41825,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41826,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41827,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41828,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 396.69,,OUTPAT REV HCPCS COMBO 1, 468.07,OTHER, 163.97, 861.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41829,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41830,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 357.77,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41831,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 357.77,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41832,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 357.77,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41833,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 357.77,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41834,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 352.09,,OUTPAT REV HCPCS COMBO 1, 419.41,OTHER, 141.55, 776.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41835,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41836,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41837,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41838,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41839,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41840,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 352.09,,OUTPAT REV HCPCS COMBO 1, 414.50,OTHER, 141.55, 764.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41841,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41842,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 169.31,,OUTPAT REV HCPCS COMBO 1, 214.87,OTHER, 133.37, 367.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41843,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41844,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 346.76,,OUTPAT REV HCPCS COMBO 1, 408.73,OTHER, 141.55, 752.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41845,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41846,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 438.13,,OUTPAT REV HCPCS COMBO 1, 507.55,OTHER, 141.55, 950.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41847,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41848,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 697.12,,OUTPAT REV HCPCS COMBO 1, 775.60,OTHER, 90.89, 1513.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41849,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41850,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 239.30,,OUTPAT REV HCPCS COMBO 1, 290.56,OTHER, 133.37, 519.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41851,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41852,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 356.96,,OUTPAT REV HCPCS COMBO 1, 419.77,OTHER, 141.55, 774.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41853,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41854,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 404.87,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41855,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 404.87,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41856,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 404.87,,OUTPAT REV HCPCS COMBO 1, 471.58,OTHER, 141.55, 878.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41857,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41858,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41859,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41860,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 282.53,,OUTPAT REV HCPCS COMBO 1, 322.12,OTHER, 90.89, 613.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41861,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 273.12,,OUTPAT REV HCPCS COMBO 1, 322.12,OTHER, 90.89, 613.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41862,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41863,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41864,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 346.52,,OUTPAT REV HCPCS COMBO 1, 408.48,OTHER, 141.55, 752.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41865,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41866,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 722.40,,OUTPAT REV HCPCS COMBO 1, 813.95,OTHER, 137.10, 1568.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41867,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 456.76,,OUTPAT REV HCPCS COMBO 1, 526.64,OTHER, 137.10, 991.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41868,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 456.76,,OUTPAT REV HCPCS COMBO 1, 526.64,OTHER, 137.10, 991.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41869,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41870,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41871,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41872,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 162.07,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41873,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 248.33,,OUTPAT REV HCPCS COMBO 1, 300.33,OTHER, 133.37, 539.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41874,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 162.07,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41875,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 162.07,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41876,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 162.07,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41877,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 162.07,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41878,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 162.07,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41879,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 162.07,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41880,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 162.07,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 133.37, 351.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41881,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41882,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41883,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41884,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41885,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41886,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41887,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41888,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41889,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41890,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 300.20,,OUTPAT REV HCPCS COMBO 1, 426.14,OTHER, 285.90, 651.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41891,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41892,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 191.70,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41893,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 191.70,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41894,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 191.70,,OUTPAT REV HCPCS COMBO 1, 272.12,OTHER, 182.57, 416.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41895,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41896,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41897,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41898,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41899,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 131.39,,OUTPAT REV HCPCS COMBO 1, 186.51,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41900,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 131.39,,OUTPAT REV HCPCS COMBO 1, 186.51,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41901,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 64.11,,OUTPAT REV HCPCS COMBO 1, 91.01,OTHER, 61.06, 139.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41902,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 22.20,,OUTPAT REV HCPCS COMBO 1, 78.82,OTHER, 21.15, 181.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41903,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 131.39,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41904,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 131.39,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41905,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 131.39,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41906,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 131.39,,OUTPAT REV HCPCS COMBO 1, 185.61,OTHER, 125.13, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41907,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41908,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41909,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41910,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41911,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 221.24,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41912,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 184.66,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41913,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 221.24,,OUTPAT REV HCPCS COMBO 1, 281.03,OTHER, 175.87, 480.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41914,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41915,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41916,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 85.51,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41917,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 85.51,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41918,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 85.51,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41919,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 85.51,,OUTPAT REV HCPCS COMBO 1, 171.54,OTHER, 81.44, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41920,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 85.51,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41921,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 85.51,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41922,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 85.51,,OUTPAT REV HCPCS COMBO 1, 235.21,OTHER, 81.44, 588.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41923,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41924,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41925,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41926,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41927,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41928,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41929,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41930,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 77.21,,OUTPAT REV HCPCS COMBO 1, 116.40,OTHER, 73.53, 167.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41931,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41932,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 331.78,,OUTPAT REV HCPCS COMBO 1, 414.07,OTHER, 232.03, 720.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41933,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 88.49,,OUTPAT REV HCPCS COMBO 1, 158.67,OTHER, 84.28, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41934,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 158.48,,OUTPAT REV HCPCS COMBO 1, 158.67,OTHER, 84.28, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41935,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41936,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41937,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 133.64,,OUTPAT REV HCPCS COMBO 1, 154.63,OTHER, 42.36, 290.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41938,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 158.48,,OUTPAT REV HCPCS COMBO 1, 204.30,OTHER, 138.19, 343.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41939,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41940,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 576.49,,OUTPAT REV HCPCS COMBO 1, 660.83,OTHER, 156.82, 1251.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41941,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 576.49,,OUTPAT REV HCPCS COMBO 1, 660.83,OTHER, 156.82, 1251.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41942,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41943,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41944,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 448.14,,OUTPAT REV HCPCS COMBO 1, 533.81,OTHER, 206.35, 972.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41945,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 448.14,,OUTPAT REV HCPCS COMBO 1, 533.81,OTHER, 206.35, 972.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41946,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41947,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41948,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 630.25,,OUTPAT REV HCPCS COMBO 1, 757.92,OTHER, 320.35, 1367.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41949,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41950,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 760.95,,OUTPAT REV HCPCS COMBO 1, 899.81,OTHER, 322.62, 1651.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41951,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41952,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 889.46,,OUTPAT REV HCPCS COMBO 1, 1092.65,OTHER, 548.80, 1930.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41953,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41954,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 705.75,,OUTPAT REV HCPCS COMBO 1, 864.03,OTHER, 423.08, 1531.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41955,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41956,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 225.75,,OUTPAT REV HCPCS COMBO 1, 344.89,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41957,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41958,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 677.25,,OUTPAT REV HCPCS COMBO 1, 830.31,OTHER, 410.92, 1470.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41959,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41960,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 930.09,,OUTPAT REV HCPCS COMBO 1, 1103.77,OTHER, 410.92, 2018.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41961,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41962,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 948.15,,OUTPAT REV HCPCS COMBO 1, 1111.16,OTHER, 359.95, 2058.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41963,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41964,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 497.78,,OUTPAT REV HCPCS COMBO 1, 624.07,OTHER, 359.95, 1080.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41965,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41966,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 542.40,,OUTPAT REV HCPCS COMBO 1, 672.34,OTHER, 360.01, 1177.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41967,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41968,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 437.96,,OUTPAT REV HCPCS COMBO 1, 559.38,OTHER, 360.01, 950.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41969,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41970,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1056.22,,OUTPAT REV HCPCS COMBO 1, 1228.06,OTHER, 360.01, 2292.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41971,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41972,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1117.24,,OUTPAT REV HCPCS COMBO 1, 1294.05,OTHER, 360.01, 2425.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41973,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41974,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 494.39,,OUTPAT REV HCPCS COMBO 1, 701.80,OTHER, 470.85, 1073.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41975,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41976,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 814.28,,OUTPAT REV HCPCS COMBO 1, 1149.19,OTHER, 775.51, 1767.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41977,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 814.28,,OUTPAT REV HCPCS COMBO 1, 1149.19,OTHER, 775.51, 1767.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41978,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41979,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41980,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1848.57,,OUTPAT REV HCPCS COMBO 1, 2267.81,OTHER, 1127.76, 4012.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41981,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41982,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 655.62,,OUTPAT REV HCPCS COMBO 1, 815.01,OTHER, 444.92, 1423.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41983,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 655.62,,OUTPAT REV HCPCS COMBO 1, 815.01,OTHER, 444.92, 1423.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41984,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41985,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41986,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 525.43,,OUTPAT REV HCPCS COMBO 1, 635.79,OTHER, 283.54, 1140.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41987,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41988,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 843.78,,OUTPAT REV HCPCS COMBO 1, 984.09,OTHER, 300.36, 1831.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41989,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41990,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 873.35,,OUTPAT REV HCPCS COMBO 1, 1050.06,OTHER, 443.12, 1895.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41991,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41992,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 469.56,,OUTPAT REV HCPCS COMBO 1, 684.67,OTHER, 447.20, 1019.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41993,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41994,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2150.95,,OUTPAT REV HCPCS COMBO 1, 2685.69,OTHER, 1509.32, 4668.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41995,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41996,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2227.70,,OUTPAT REV HCPCS COMBO 1, 2768.70,OTHER, 1509.32, 4835.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41997,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 41998,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 27.36,,OUTPAT REV HCPCS COMBO 1, 34.30,OTHER, 19.78, 59.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 41999,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 27.36,,OUTPAT REV HCPCS COMBO 1, 32.49,OTHER, 12.18, 59.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42000,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 280.83,,OUTPAT REV HCPCS COMBO 1, 398.65,OTHER, 267.46, 609.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42001,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 63.14,,OUTPAT REV HCPCS COMBO 1, 70.69,OTHER, 10.09, 137.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42002,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 109.60,,OUTPAT REV HCPCS COMBO 1, 122.16,OTHER, 15.20, 237.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42003,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 86.00,,OUTPAT REV HCPCS COMBO 1, 97.60,OTHER, 19.28, 186.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42004,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 86.00,,OUTPAT REV HCPCS COMBO 1, 97.60,OTHER, 19.28, 186.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42005,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 74.50,,OUTPAT REV HCPCS COMBO 1, 83.55,OTHER, 12.50, 161.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42006,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 74.50,,OUTPAT REV HCPCS COMBO 1, 83.55,OTHER, 12.50, 161.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42007,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 129.00,,OUTPAT REV HCPCS COMBO 1, 155.85,OTHER, 68.59, 280.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42008,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 70.44,,OUTPAT REV HCPCS COMBO 1, 78.98,OTHER, 11.76, 152.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42009,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 59.15,,OUTPAT REV HCPCS COMBO 1, 69.30,OTHER, 22.37, 128.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42010,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 201.82,,OUTPAT REV HCPCS COMBO 1, 229.30,OTHER, 46.28, 438.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42011,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 79.58,,OUTPAT REV HCPCS COMBO 1, 88.95,OTHER, 20.98, 172.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42012,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 75.67,,OUTPAT REV HCPCS COMBO 1, 88.95,OTHER, 20.98, 172.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42013,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 45.15,,OUTPAT REV HCPCS COMBO 1, 53.39,OTHER, 19.13, 98.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42014,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 45.15,,OUTPAT REV HCPCS COMBO 1, 53.39,OTHER, 19.13, 98.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42015,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.83,,OUTPAT REV HCPCS COMBO 1, 80.17,OTHER, 19.50, 151.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42016,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 43.62,,OUTPAT REV HCPCS COMBO 1, 54.61,OTHER, 31.20, 94.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42017,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.79,,OUTPAT REV HCPCS COMBO 1, 80.03,OTHER, 19.08, 151.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42018,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.00,,OUTPAT REV HCPCS COMBO 1, 79.17,OTHER, 19.08, 149.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42019,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 57.03,,OUTPAT REV HCPCS COMBO 1, 63.95,OTHER, 9.52, 123.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42020,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 21.22,,OUTPAT REV HCPCS COMBO 1, 28.28,OTHER, 20.21, 46.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42021,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 73.18,,OUTPAT REV HCPCS COMBO 1, 83.69,OTHER, 19.08, 158.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42022,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 44.59,,OUTPAT REV HCPCS COMBO 1, 53.47,OTHER, 22.03, 96.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42023,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.59,,OUTPAT REV HCPCS COMBO 1, 79.81,OTHER, 19.08, 151.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42024,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 36.92,,OUTPAT REV HCPCS COMBO 1, 44.64,OTHER, 19.78, 80.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42025,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 130.56,,OUTPAT REV HCPCS COMBO 1, 145.91,OTHER, 19.78, 283.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42026,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 55.40,,OUTPAT REV HCPCS COMBO 1, 64.76,OTHER, 20.36, 120.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42027,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 108.41,,OUTPAT REV HCPCS COMBO 1, 121.34,OTHER, 17.16, 235.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42028,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 74.07,,OUTPAT REV HCPCS COMBO 1, 84.76,OTHER, 19.50, 160.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42029,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 117.38,,OUTPAT REV HCPCS COMBO 1, 134.69,OTHER, 32.53, 254.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42030,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 78.15,,OUTPAT REV HCPCS COMBO 1, 90.91,OTHER, 26.84, 169.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42031,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 85.94,,OUTPAT REV HCPCS COMBO 1, 56.90,OTHER, 10.75, 186.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42032,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 11.29,,OUTPAT REV HCPCS COMBO 1, 56.90,OTHER, 10.75, 186.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42033,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 18.06,,OUTPAT REV HCPCS COMBO 1, 23.85,OTHER, 17.20, 39.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42034,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 18.06,,OUTPAT REV HCPCS COMBO 1, 23.85,OTHER, 17.20, 39.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42035,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 118.24,,OUTPAT REV HCPCS COMBO 1, 178.46,OTHER, 112.61, 289.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42036,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 133.19,,OUTPAT REV HCPCS COMBO 1, 178.46,OTHER, 112.61, 289.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42037,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 76.30,,OUTPAT REV HCPCS COMBO 1, 108.31,OTHER, 72.67, 165.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42038,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.73,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42039,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 34.31,,OUTPAT REV HCPCS COMBO 1, 48.71,OTHER, 32.68, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42040,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 126.77,,OUTPAT REV HCPCS COMBO 1, 179.95,OTHER, 120.73, 275.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42041,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 80.75,,OUTPAT REV HCPCS COMBO 1, 114.63,OTHER, 76.91, 175.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42042,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 18.43,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42043,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.86,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42044,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 18.43,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42045,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 18.43,,OUTPAT REV HCPCS COMBO 1, 26.17,OTHER, 17.56, 40.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42046,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 63.66,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42047,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.81,,OUTPAT REV HCPCS COMBO 1, 67.87,OTHER, 45.53, 103.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42048,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 71.79,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42049,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 71.79,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42050,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 71.79,,OUTPAT REV HCPCS COMBO 1, 101.91,OTHER, 68.37, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42051,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 60.95,,OUTPAT REV HCPCS COMBO 1, 86.52,OTHER, 58.05, 132.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42052,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.83,,OUTPAT REV HCPCS COMBO 1, 120.81,OTHER, 36.98, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42053,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 131.39,,OUTPAT REV HCPCS COMBO 1, 120.81,OTHER, 36.98, 285.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42054,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 31.25,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42055,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 31.25,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42056,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 31.25,,OUTPAT REV HCPCS COMBO 1, 34.88,OTHER, 4.56, 67.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42057,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 18.64,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42058,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 18.64,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42059,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 18.64,,OUTPAT REV HCPCS COMBO 1, 20.93,OTHER, 3.24, 40.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42060,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 5.87,,OUTPAT REV HCPCS COMBO 1, 7.12,OTHER, 3.24, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42061,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 6.77,,OUTPAT REV HCPCS COMBO 1, 8.07,OTHER, 3.12, 14.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42062,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 28.58,,OUTPAT REV HCPCS COMBO 1, 33.86,OTHER, 12.40, 62.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42063,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 28.58,,OUTPAT REV HCPCS COMBO 1, 33.86,OTHER, 12.40, 62.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42064,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.27,,OUTPAT REV HCPCS COMBO 1, 75.71,OTHER, 12.40, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42065,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.27,,OUTPAT REV HCPCS COMBO 1, 75.71,OTHER, 12.40, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42066,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 111.36,,OUTPAT REV HCPCS COMBO 1, 145.60,OTHER, 105.66, 241.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42067,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 111.36,,OUTPAT REV HCPCS COMBO 1, 145.60,OTHER, 105.66, 241.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42068,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 222.14,,OUTPAT REV HCPCS COMBO 1, 262.66,OTHER, 94.12, 482.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42069,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 367.58,,OUTPAT REV HCPCS COMBO 1, 428.98,OTHER, 131.99, 797.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42070,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 91.36,,OUTPAT REV HCPCS COMBO 1, 129.68,OTHER, 87.01, 198.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42071,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 172.47,,OUTPAT REV HCPCS COMBO 1, 244.83,OTHER, 164.26, 374.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42072,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 172.47,,OUTPAT REV HCPCS COMBO 1, 244.83,OTHER, 164.26, 374.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42073,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.71,,OUTPAT REV HCPCS COMBO 1, 53.15,OTHER, 6.50, 103.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42074,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.38,,OUTPAT REV HCPCS COMBO 1, 38.90,OTHER, 11.76, 72.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42075,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 123.52,,OUTPAT REV HCPCS COMBO 1, 146.83,OTHER, 55.61, 268.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42076,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 17.04,,OUTPAT REV HCPCS COMBO 1, 20.13,OTHER, 7.13, 37.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42077,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 17.04,,OUTPAT REV HCPCS COMBO 1, 20.13,OTHER, 7.13, 37.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42078,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 24.27,,OUTPAT REV HCPCS COMBO 1, 28.92,OTHER, 11.21, 52.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42079,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 24.27,,OUTPAT REV HCPCS COMBO 1, 28.92,OTHER, 11.21, 52.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42080,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 54.18,,OUTPAT REV HCPCS COMBO 1, 60.58,OTHER, 8.33, 117.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42081,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 54.18,,OUTPAT REV HCPCS COMBO 1, 60.58,OTHER, 8.33, 117.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42082,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 43.96,,OUTPAT REV HCPCS COMBO 1, 50.88,OTHER, 13.98, 95.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42083,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 61.44,,OUTPAT REV HCPCS COMBO 1, 71.06,OTHER, 19.36, 133.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42084,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 97.00,,OUTPAT REV HCPCS COMBO 1, 109.86,OTHER, 20.82, 210.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42085,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 68.80,,OUTPAT REV HCPCS COMBO 1, 80.16,OTHER, 24.14, 149.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42086,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 68.80,,OUTPAT REV HCPCS COMBO 1, 80.16,OTHER, 24.14, 149.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42087,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 53.73,,OUTPAT REV HCPCS COMBO 1, 63.10,OTHER, 20.98, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42088,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 53.73,,OUTPAT REV HCPCS COMBO 1, 63.10,OTHER, 20.98, 116.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42089,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 44.91,,OUTPAT REV HCPCS COMBO 1, 50.79,OTHER, 9.34, 97.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42090,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 44.91,,OUTPAT REV HCPCS COMBO 1, 50.79,OTHER, 9.34, 97.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42091,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 83.53,,OUTPAT REV HCPCS COMBO 1, 100.38,OTHER, 42.16, 181.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42092,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 102.53,,OUTPAT REV HCPCS COMBO 1, 121.92,OTHER, 46.34, 222.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42093,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 39.73,,OUTPAT REV HCPCS COMBO 1, 50.20,OTHER, 30.37, 86.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42094,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 101.53,,OUTPAT REV HCPCS COMBO 1, 116.31,OTHER, 27.31, 220.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42095,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 42.89,,OUTPAT REV HCPCS COMBO 1, 49.78,OTHER, 14.24, 93.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42096,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 53.53,,OUTPAT REV HCPCS COMBO 1, 63.44,OTHER, 23.30, 116.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42097,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 32.03,,OUTPAT REV HCPCS COMBO 1, 36.36,OTHER, 7.22, 69.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42098,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 32.03,,OUTPAT REV HCPCS COMBO 1, 36.36,OTHER, 7.22, 69.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42099,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 28.99,,OUTPAT REV HCPCS COMBO 1, 33.07,OTHER, 7.22, 62.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42100,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 16.48,,OUTPAT REV HCPCS COMBO 1, 19.33,OTHER, 6.31, 35.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42101,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 29.42,,OUTPAT REV HCPCS COMBO 1, 33.34,OTHER, 6.38, 63.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42102,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.41,,OUTPAT REV HCPCS COMBO 1, 56.73,OTHER, 22.92, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42103,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 105.40,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42104,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 112.42,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42105,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 105.40,,OUTPAT REV HCPCS COMBO 1, 126.67,OTHER, 42.62, 244.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42106,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 105.84,,OUTPAT REV HCPCS COMBO 1, 123.66,OTHER, 38.58, 229.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42107,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 29.88,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42108,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 29.88,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42109,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 29.88,,OUTPAT REV HCPCS COMBO 1, 34.08,OTHER, 7.43, 64.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42110,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 59.68,,OUTPAT REV HCPCS COMBO 1, 69.24,OTHER, 19.70, 129.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42111,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 44.29,,OUTPAT REV HCPCS COMBO 1, 49.97,OTHER, 8.69, 96.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42112,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 37.02,,OUTPAT REV HCPCS COMBO 1, 44.47,OTHER, 18.58, 80.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42113,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 56.32,,OUTPAT REV HCPCS COMBO 1, 65.14,OTHER, 17.74, 122.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42114,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 74.66,,OUTPAT REV HCPCS COMBO 1, 87.25,OTHER, 27.30, 162.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42115,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 74.66,,OUTPAT REV HCPCS COMBO 1, 87.25,OTHER, 27.30, 162.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42116,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 49.21,,OUTPAT REV HCPCS COMBO 1, 59.01,OTHER, 24.29, 106.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42117,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 109.76,,OUTPAT REV HCPCS COMBO 1, 127.93,OTHER, 36.36, 240.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42118,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 110.81,,OUTPAT REV HCPCS COMBO 1, 127.93,OTHER, 36.36, 240.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42119,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 48.79,,OUTPAT REV HCPCS COMBO 1, 56.46,OTHER, 15.47, 105.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42120,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 10.84,,OUTPAT REV HCPCS COMBO 1, 13.69,OTHER, 8.28, 23.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42121,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 64.22,,OUTPAT REV HCPCS COMBO 1, 73.71,OTHER, 17.87, 139.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42122,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 75.82,,OUTPAT REV HCPCS COMBO 1, 87.73,OTHER, 24.06, 164.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42123,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 75.82,,OUTPAT REV HCPCS COMBO 1, 87.73,OTHER, 24.06, 164.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42124,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 56.14,,OUTPAT REV HCPCS COMBO 1, 66.31,OTHER, 23.47, 121.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42125,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 56.14,,OUTPAT REV HCPCS COMBO 1, 66.31,OTHER, 23.47, 121.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42126,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 168.21,,OUTPAT REV HCPCS COMBO 1, 190.19,OTHER, 34.69, 365.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42127,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 190.24,,OUTPAT REV HCPCS COMBO 1, 214.01,OTHER, 34.69, 412.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42128,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 41.85,,OUTPAT REV HCPCS COMBO 1, 47.49,OTHER, 9.37, 90.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42129,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 41.85,,OUTPAT REV HCPCS COMBO 1, 47.49,OTHER, 9.37, 90.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42130,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 34.31,,OUTPAT REV HCPCS COMBO 1, 41.70,OTHER, 19.28, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42131,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 51.56,,OUTPAT REV HCPCS COMBO 1, 59.73,OTHER, 16.63, 111.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42132,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 27.62,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42133,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 27.62,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42134,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 27.62,,OUTPAT REV HCPCS COMBO 1, 31.62,OTHER, 7.37, 59.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42135,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 34.52,,OUTPAT REV HCPCS COMBO 1, 39.11,OTHER, 7.46, 74.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42136,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 34.52,,OUTPAT REV HCPCS COMBO 1, 39.11,OTHER, 7.46, 74.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42137,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 83.42,,OUTPAT REV HCPCS COMBO 1, 93.47,OTHER, 13.62, 181.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42138,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 83.42,,OUTPAT REV HCPCS COMBO 1, 93.47,OTHER, 13.62, 181.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42139,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 37.93,,OUTPAT REV HCPCS COMBO 1, 45.06,OTHER, 16.97, 82.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42140,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 68.42,,OUTPAT REV HCPCS COMBO 1, 76.21,OTHER, 9.31, 148.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42141,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 62.00,,OUTPAT REV HCPCS COMBO 1, 72.23,OTHER, 21.72, 134.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42142,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 62.00,,OUTPAT REV HCPCS COMBO 1, 72.23,OTHER, 21.72, 134.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42143,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 63.81,,OUTPAT REV HCPCS COMBO 1, 75.36,OTHER, 26.66, 138.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42144,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 63.81,,OUTPAT REV HCPCS COMBO 1, 75.36,OTHER, 26.66, 138.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42145,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 109.80,,OUTPAT REV HCPCS COMBO 1, 127.42,OTHER, 36.38, 238.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42146,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 109.80,,OUTPAT REV HCPCS COMBO 1, 127.42,OTHER, 36.38, 238.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42147,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 80.84,,OUTPAT REV HCPCS COMBO 1, 93.87,OTHER, 27.06, 175.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42148,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 116.41,,OUTPAT REV HCPCS COMBO 1, 135.49,OTHER, 40.24, 252.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42149,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 116.41,,OUTPAT REV HCPCS COMBO 1, 135.49,OTHER, 40.24, 252.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42150,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.27,,OUTPAT REV HCPCS COMBO 1, 83.83,OTHER, 46.51, 146.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42151,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 60.50,,OUTPAT REV HCPCS COMBO 1, 73.72,OTHER, 34.82, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42152,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 61.86,,OUTPAT REV HCPCS COMBO 1, 75.45,OTHER, 35.93, 134.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42153,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 105.09,,OUTPAT REV HCPCS COMBO 1, 121.64,OTHER, 33.53, 228.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42154,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 62.33,,OUTPAT REV HCPCS COMBO 1, 69.17,OTHER, 7.34, 135.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42155,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 109.94,,OUTPAT REV HCPCS COMBO 1, 124.67,OTHER, 24.19, 238.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42156,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 66.37,,OUTPAT REV HCPCS COMBO 1, 76.46,OTHER, 19.63, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42157,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 61.43,,OUTPAT REV HCPCS COMBO 1, 71.48,OTHER, 21.17, 133.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42158,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 191.33,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42159,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.99,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42160,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.75,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42161,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.75,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42162,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.75,,OUTPAT REV HCPCS COMBO 1, 90.70,OTHER, 13.39, 415.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42163,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 54.84,,OUTPAT REV HCPCS COMBO 1, 64.96,OTHER, 23.70, 119.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42164,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 29.80,,OUTPAT REV HCPCS COMBO 1, 34.98,OTHER, 11.54, 64.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42165,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 179.91,,OUTPAT REV HCPCS COMBO 1, 203.52,OTHER, 37.54, 390.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42166,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 51.47,,OUTPAT REV HCPCS COMBO 1, 61.71,OTHER, 25.39, 111.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42167,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 22.46,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42168,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 22.46,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42169,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 22.46,,OUTPAT REV HCPCS COMBO 1, 25.64,OTHER, 5.66, 48.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42170,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 24.94,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42171,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 24.94,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42172,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 24.94,,OUTPAT REV HCPCS COMBO 1, 28.32,OTHER, 5.66, 54.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42173,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 11.83,,OUTPAT REV HCPCS COMBO 1, 14.14,OTHER, 5.66, 25.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42174,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 58.09,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 6.84, 126.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42175,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 58.09,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 6.84, 126.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42176,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 50.47,,OUTPAT REV HCPCS COMBO 1, 57.91,OTHER, 13.97, 109.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42177,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 32.43,,OUTPAT REV HCPCS COMBO 1, 37.55,OTHER, 10.37, 70.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42178,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 81.70,,OUTPAT REV HCPCS COMBO 1, 94.73,OTHER, 26.76, 177.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42179,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 81.70,,OUTPAT REV HCPCS COMBO 1, 94.73,OTHER, 26.76, 177.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42180,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 81.52,,OUTPAT REV HCPCS COMBO 1, 94.52,OTHER, 26.66, 176.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42181,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 81.52,,OUTPAT REV HCPCS COMBO 1, 94.52,OTHER, 26.66, 176.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42182,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 58.00,,OUTPAT REV HCPCS COMBO 1, 67.05,OTHER, 18.12, 125.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42183,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 62.31,,OUTPAT REV HCPCS COMBO 1, 74.92,OTHER, 31.62, 135.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42184,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 41.58,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42185,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 41.58,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42186,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 41.58,,OUTPAT REV HCPCS COMBO 1, 48.30,OTHER, 13.98, 90.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42187,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 86.62,,OUTPAT REV HCPCS COMBO 1, 99.83,OTHER, 25.80, 188.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42188,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 135.90,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42189,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 119.82,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42190,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 119.82,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42191,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 119.82,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42192,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 119.82,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42193,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 119.82,,OUTPAT REV HCPCS COMBO 1, 136.44,OTHER, 16.61, 294.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42194,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 133.92,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42195,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 80.85,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42196,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 124.65,,OUTPAT REV HCPCS COMBO 1, 128.28,OTHER, 24.86, 290.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42197,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 19.41,,OUTPAT REV HCPCS COMBO 1, 25.93,OTHER, 18.49, 42.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42198,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 60.21,,OUTPAT REV HCPCS COMBO 1, 69.04,OTHER, 16.46, 130.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42199,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.52,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42200,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.52,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42201,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.52,,OUTPAT REV HCPCS COMBO 1, 43.88,OTHER, 9.31, 83.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42202,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.14,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42203,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.14,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42204,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.14,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42205,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.14,,OUTPAT REV HCPCS COMBO 1, 53.98,OTHER, 12.59, 102.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42206,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 61.09,,OUTPAT REV HCPCS COMBO 1, 70.04,OTHER, 16.66, 132.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42207,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 39.04,,OUTPAT REV HCPCS COMBO 1, 51.00,OTHER, 8.70, 111.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42208,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 51.43,,OUTPAT REV HCPCS COMBO 1, 51.00,OTHER, 8.70, 111.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42209,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 74.95,,OUTPAT REV HCPCS COMBO 1, 85.45,OTHER, 18.42, 162.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42210,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 57.34,,OUTPAT REV HCPCS COMBO 1, 68.77,OTHER, 28.37, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42211,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 46.80,,OUTPAT REV HCPCS COMBO 1, 54.77,OTHER, 17.44, 101.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42212,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 46.80,,OUTPAT REV HCPCS COMBO 1, 54.77,OTHER, 17.44, 101.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42213,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 53.73,,OUTPAT REV HCPCS COMBO 1, 60.48,OTHER, 9.92, 116.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42214,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 53.73,,OUTPAT REV HCPCS COMBO 1, 60.48,OTHER, 9.92, 116.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42215,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 123.13,,OUTPAT REV HCPCS COMBO 1, 149.05,OTHER, 66.68, 267.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42216,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 29.35,,OUTPAT REV HCPCS COMBO 1, 43.46,OTHER, 27.95, 63.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42217,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 36.44,,OUTPAT REV HCPCS COMBO 1, 43.01,OTHER, 15.12, 79.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42218,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 36.44,,OUTPAT REV HCPCS COMBO 1, 43.01,OTHER, 15.12, 79.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42219,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 35.45,,OUTPAT REV HCPCS COMBO 1, 40.64,OTHER, 9.65, 76.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42220,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 181.01,,OUTPAT REV HCPCS COMBO 1, 204.04,OTHER, 34.72, 392.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42221,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 48.00,,OUTPAT REV HCPCS COMBO 1, 57.49,OTHER, 23.41, 104.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42222,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 142.16,,OUTPAT REV HCPCS COMBO 1, 159.56,OTHER, 24.40, 308.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42223,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 142.16,,OUTPAT REV HCPCS COMBO 1, 159.56,OTHER, 24.40, 308.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42224,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 75.25,,OUTPAT REV HCPCS COMBO 1, 74.79,OTHER, 18.60, 163.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42225,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 54.87,,OUTPAT REV HCPCS COMBO 1, 74.79,OTHER, 18.60, 163.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42226,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 98.88,,OUTPAT REV HCPCS COMBO 1, 120.40,OTHER, 56.53, 214.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42227,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 98.88,,OUTPAT REV HCPCS COMBO 1, 120.40,OTHER, 56.53, 214.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42228,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 95.87,,OUTPAT REV HCPCS COMBO 1, 110.95,OTHER, 30.54, 208.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42229,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.99,,OUTPAT REV HCPCS COMBO 1, 54.17,OTHER, 9.52, 104.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42230,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.94,,OUTPAT REV HCPCS COMBO 1, 44.45,OTHER, 9.82, 84.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42231,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.94,,OUTPAT REV HCPCS COMBO 1, 44.45,OTHER, 9.82, 84.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42232,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 75.07,,OUTPAT REV HCPCS COMBO 1, 86.15,OTHER, 20.81, 162.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42233,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 122.83,,OUTPAT REV HCPCS COMBO 1, 147.00,OTHER, 59.45, 266.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42234,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 122.83,,OUTPAT REV HCPCS COMBO 1, 147.00,OTHER, 59.45, 266.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42235,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 34.31,,OUTPAT REV HCPCS COMBO 1, 43.75,OTHER, 27.89, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42236,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 166.32,,OUTPAT REV HCPCS COMBO 1, 186.61,OTHER, 28.27, 361.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42237,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.83,,OUTPAT REV HCPCS COMBO 1, 45.87,OTHER, 7.46, 92.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42238,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 42.71,,OUTPAT REV HCPCS COMBO 1, 45.87,OTHER, 7.46, 92.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42239,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 31.04,,OUTPAT REV HCPCS COMBO 1, 35.19,OTHER, 6.83, 67.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42240,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 31.04,,OUTPAT REV HCPCS COMBO 1, 35.19,OTHER, 6.83, 67.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42241,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 25.18,,OUTPAT REV HCPCS COMBO 1, 28.87,OTHER, 6.85, 54.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42242,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 11.29,,OUTPAT REV HCPCS COMBO 1, 13.83,OTHER, 6.82, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42243,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 37.50,,OUTPAT REV HCPCS COMBO 1, 45.56,OTHER, 21.01, 81.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42244,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 79.12,,OUTPAT REV HCPCS COMBO 1, 92.72,OTHER, 30.04, 171.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42245,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 79.12,,OUTPAT REV HCPCS COMBO 1, 92.72,OTHER, 30.04, 171.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42246,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 86.42,,OUTPAT REV HCPCS COMBO 1, 102.79,OTHER, 39.19, 187.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42247,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 83.70,,OUTPAT REV HCPCS COMBO 1, 97.17,OTHER, 27.91, 181.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42248,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 74.64,,OUTPAT REV HCPCS COMBO 1, 90.21,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42249,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 80.52,,OUTPAT REV HCPCS COMBO 1, 90.21,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42250,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 80.52,,OUTPAT REV HCPCS COMBO 1, 93.39,OTHER, 26.48, 174.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42251,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 21.64,,OUTPAT REV HCPCS COMBO 1, 24.66,OTHER, 5.28, 46.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42252,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 21.64,,OUTPAT REV HCPCS COMBO 1, 24.66,OTHER, 5.28, 46.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42253,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 52.32,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42254,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 52.32,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42255,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 52.32,,OUTPAT REV HCPCS COMBO 1, 57.84,OTHER, 5.28, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42256,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 36.93,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42257,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 36.93,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42258,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.57,,OUTPAT REV HCPCS COMBO 1, 41.90,OTHER, 5.76, 83.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42259,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 179.74,,OUTPAT REV HCPCS COMBO 1, 144.06,OTHER, 15.47, 390.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42260,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 79.85,,OUTPAT REV HCPCS COMBO 1, 144.06,OTHER, 15.47, 390.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42261,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 68.86,,OUTPAT REV HCPCS COMBO 1, 141.59,OTHER, 25.68, 394.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42262,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 181.67,,OUTPAT REV HCPCS COMBO 1, 141.59,OTHER, 25.68, 394.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42263,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 117.61,,OUTPAT REV HCPCS COMBO 1, 136.35,OTHER, 38.44, 255.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42264,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 86.58,,OUTPAT REV HCPCS COMBO 1, 103.27,OTHER, 40.46, 187.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42265,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 64.11,,OUTPAT REV HCPCS COMBO 1, 76.88,OTHER, 31.67, 139.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42266,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 158.93,,OUTPAT REV HCPCS COMBO 1, 178.83,OTHER, 29.15, 344.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42267,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 74.87,,OUTPAT REV HCPCS COMBO 1, 88.43,OTHER, 31.30, 162.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42268,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 26.23,,OUTPAT REV HCPCS COMBO 1, 30.02,OTHER, 6.92, 56.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42269,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 26.23,,OUTPAT REV HCPCS COMBO 1, 30.02,OTHER, 6.92, 56.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42270,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 40.80,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42271,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 40.80,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42272,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 8.38,,OUTPAT REV HCPCS COMBO 1, 34.17,OTHER, 7.28, 88.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42273,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 160.36,,OUTPAT REV HCPCS COMBO 1, 180.72,OTHER, 30.61, 348.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42274,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 277.55,,OUTPAT REV HCPCS COMBO 1, 302.95,OTHER, 11.66, 602.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42275,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.65,,OUTPAT REV HCPCS COMBO 1, 81.90,OTHER, 36.67, 146.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42276,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 105.66,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42277,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 105.66,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42278,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 105.66,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42279,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 105.66,,OUTPAT REV HCPCS COMBO 1, 123.12,OTHER, 37.16, 229.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42280,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 73.52,,OUTPAT REV HCPCS COMBO 1, 86.80,OTHER, 30.58, 159.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42281,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 73.52,,OUTPAT REV HCPCS COMBO 1, 86.80,OTHER, 30.58, 159.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42282,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 94.17,,OUTPAT REV HCPCS COMBO 1, 107.35,OTHER, 23.12, 204.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42283,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 94.17,,OUTPAT REV HCPCS COMBO 1, 107.35,OTHER, 23.12, 204.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42284,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.08,,OUTPAT REV HCPCS COMBO 1, 53.27,OTHER, 9.89, 102.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42285,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.08,,OUTPAT REV HCPCS COMBO 1, 53.27,OTHER, 9.89, 102.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42286,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.36,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42287,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.36,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42288,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.36,,OUTPAT REV HCPCS COMBO 1, 75.95,OTHER, 12.98, 146.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42289,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 43.34,,OUTPAT REV HCPCS COMBO 1, 51.95,OTHER, 21.29, 94.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42290,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 62.66,,OUTPAT REV HCPCS COMBO 1, 73.53,OTHER, 24.19, 136.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42291,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 126.42,,OUTPAT REV HCPCS COMBO 1, 154.17,OTHER, 73.24, 274.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42292,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 126.42,,OUTPAT REV HCPCS COMBO 1, 154.17,OTHER, 73.24, 274.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42293,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 41.54,,OUTPAT REV HCPCS COMBO 1, 49.79,OTHER, 20.42, 90.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42294,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.79,,OUTPAT REV HCPCS COMBO 1, 38.32,OTHER, 7.46, 73.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42295,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 31.60,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, 7.63, 68.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42296,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 50.05,,OUTPAT REV HCPCS COMBO 1, 58.51,OTHER, 18.37, 108.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42297,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 34.36,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 8.27, 74.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42298,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 68.93,,OUTPAT REV HCPCS COMBO 1, 79.41,OTHER, 20.42, 149.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42299,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 68.93,,OUTPAT REV HCPCS COMBO 1, 79.41,OTHER, 20.42, 149.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42300,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.58,,OUTPAT REV HCPCS COMBO 1, 78.90,OTHER, 24.40, 146.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42301,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.58,,OUTPAT REV HCPCS COMBO 1, 78.90,OTHER, 24.40, 146.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42302,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 112.32,,OUTPAT REV HCPCS COMBO 1, 126.89,OTHER, 22.69, 243.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42303,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 72.78,,OUTPAT REV HCPCS COMBO 1, 82.99,OTHER, 17.95, 157.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42304,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 72.78,,OUTPAT REV HCPCS COMBO 1, 82.99,OTHER, 17.95, 157.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42305,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 34.92,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42306,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 34.92,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42307,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 34.92,,OUTPAT REV HCPCS COMBO 1, 39.13,OTHER, 5.69, 75.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42308,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 19.13,,OUTPAT REV HCPCS COMBO 1, 22.60,OTHER, 8.00, 41.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42309,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 19.13,,OUTPAT REV HCPCS COMBO 1, 22.60,OTHER, 8.00, 41.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42310,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 28.04,,OUTPAT REV HCPCS COMBO 1, 31.87,OTHER, 6.50, 60.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42311,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 34.54,,OUTPAT REV HCPCS COMBO 1, 39.10,OTHER, 7.32, 74.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42312,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 66.90,,OUTPAT REV HCPCS COMBO 1, 76.33,OTHER, 16.72, 145.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42313,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 91.54,,OUTPAT REV HCPCS COMBO 1, 103.71,OTHER, 19.75, 198.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42314,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 48.80,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42315,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 48.80,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42316,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 48.80,,OUTPAT REV HCPCS COMBO 1, 56.68,OTHER, 16.40, 105.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42317,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 72.56,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 29.96, 157.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42318,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 84.95,,OUTPAT REV HCPCS COMBO 1, 97.04,OTHER, 21.67, 184.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42319,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.12,,OUTPAT REV HCPCS COMBO 1, 42.88,OTHER, 6.94, 82.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42320,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 39.29,,OUTPAT REV HCPCS COMBO 1, 43.80,OTHER, 5.47, 85.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42321,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 15.75,,OUTPAT REV HCPCS COMBO 1, 17.85,OTHER, 3.41, 34.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42322,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 15.75,,OUTPAT REV HCPCS COMBO 1, 17.85,OTHER, 3.41, 34.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42323,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 19.09,,OUTPAT REV HCPCS COMBO 1, 21.46,OTHER, 3.41, 41.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42324,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 19.09,,OUTPAT REV HCPCS COMBO 1, 21.46,OTHER, 3.41, 41.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42325,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, 22.31,OTHER, .01, 84.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42326,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.79,,OUTPAT REV HCPCS COMBO 1, 22.31,OTHER, .01, 84.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42327,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 39.29,,OUTPAT REV HCPCS COMBO 1, 44.71,OTHER, 9.31, 85.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42328,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.55,,OUTPAT REV HCPCS COMBO 1, 37.65,OTHER, 5.75, 72.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42329,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.55,,OUTPAT REV HCPCS COMBO 1, 37.65,OTHER, 5.75, 72.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42330,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 17.61,,OUTPAT REV HCPCS COMBO 1, 19.92,OTHER, 3.66, 38.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42331,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 28.75,,OUTPAT REV HCPCS COMBO 1, 32.63,OTHER, 6.46, 62.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42332,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 83.80,,OUTPAT REV HCPCS COMBO 1, 96.77,OTHER, 25.78, 181.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42333,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 112.28,,OUTPAT REV HCPCS COMBO 1, 129.31,OTHER, 33.04, 243.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42334,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 116.94,,OUTPAT REV HCPCS COMBO 1, 130.54,OTHER, 17.06, 253.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42335,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 86.54,,OUTPAT REV HCPCS COMBO 1, 98.34,OTHER, 19.93, 187.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42336,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 77.43,,OUTPAT REV HCPCS COMBO 1, 89.00,OTHER, 22.06, 168.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42337,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 87.59,,OUTPAT REV HCPCS COMBO 1, 98.22,OTHER, 14.66, 190.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42338,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.43,,OUTPAT REV HCPCS COMBO 1, 54.63,OTHER, 13.99, 102.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42339,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 59.15,,OUTPAT REV HCPCS COMBO 1, 70.40,OTHER, 27.00, 128.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42340,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 26.30,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42341,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 26.13,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42342,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 26.30,,OUTPAT REV HCPCS COMBO 1, 29.86,OTHER, 6.18, 57.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42343,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 11.74,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42344,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 11.74,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42345,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 11.74,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42346,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 11.74,,OUTPAT REV HCPCS COMBO 1, 14.17,OTHER, 6.18, 25.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42347,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 37.11,,OUTPAT REV HCPCS COMBO 1, 41.60,OTHER, 6.14, 80.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42348,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 23.48,,OUTPAT REV HCPCS COMBO 1, 26.32,OTHER, 3.89, 50.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42349,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 31.86,,OUTPAT REV HCPCS COMBO 1, 36.35,OTHER, 7.93, 69.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42350,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 76.76,,OUTPAT REV HCPCS COMBO 1, 61.85,OTHER, 8.65, 166.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42351,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.81,,OUTPAT REV HCPCS COMBO 1, 61.85,OTHER, 8.65, 166.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42352,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 68.41,,OUTPAT REV HCPCS COMBO 1, 76.67,OTHER, 11.26, 148.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42353,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 536.54,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42354,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 145.83,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42355,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42356,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42357,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42358,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42359,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42360,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42361,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42362,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42363,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42364,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42365,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42366,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42367,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42368,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42369,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42370,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42371,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42372,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42373,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42374,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42375,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42376,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42377,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42378,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42379,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42380,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42381,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42382,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42383,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42384,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42385,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42386,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42387,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42388,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42389,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42390,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42391,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 27.83,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42392,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42393,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42394,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42395,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42396,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 14.49,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42397,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42398,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42399,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42400,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42401,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42402,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42403,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42404,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42405,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42406,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42407,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42408,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42409,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42410,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42411,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42412,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42413,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42414,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.11,,OUTPAT REV HCPCS COMBO 1, 44.89,OTHER, 7.51, 1164.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42415,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 169.20,,OUTPAT REV HCPCS COMBO 1, 189.29,OTHER, 26.45, 367.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42416,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 103.31,,OUTPAT REV HCPCS COMBO 1, 115.17,OTHER, 14.46, 224.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42417,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 60.18,,OUTPAT REV HCPCS COMBO 1, 91.70,OTHER, 17.41, 220.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42418,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 101.71,,OUTPAT REV HCPCS COMBO 1, 91.70,OTHER, 17.41, 220.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42419,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 41.69,,OUTPAT REV HCPCS COMBO 1, 48.91,OTHER, 16.07, 90.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42420,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 39.51,,OUTPAT REV HCPCS COMBO 1, 45.23,OTHER, 10.51, 85.75,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42421,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 14.15,,OUTPAT REV HCPCS COMBO 1, 17.08,OTHER, 7.46, 30.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42422,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 14.15,,OUTPAT REV HCPCS COMBO 1, 17.08,OTHER, 7.46, 30.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42423,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 50.68,,OUTPAT REV HCPCS COMBO 1, 59.25,OTHER, 18.65, 110.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42424,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 78.83,,OUTPAT REV HCPCS COMBO 1, 93.98,OTHER, 36.65, 171.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42425,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 118.95,,OUTPAT REV HCPCS COMBO 1, 137.37,OTHER, 36.65, 258.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42426,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.45,,OUTPAT REV HCPCS COMBO 1, 78.46,OTHER, 23.14, 146.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42427,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 58.81,,OUTPAT REV HCPCS COMBO 1, 67.64,OTHER, 17.28, 127.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42428,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 58.66,,OUTPAT REV HCPCS COMBO 1, 67.64,OTHER, 17.28, 127.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42429,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 65.39,,OUTPAT REV HCPCS COMBO 1, 77.69,OTHER, 29.26, 141.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42430,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 54.32,,OUTPAT REV HCPCS COMBO 1, 63.19,OTHER, 18.65, 117.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42431,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 54.24,,OUTPAT REV HCPCS COMBO 1, 65.88,OTHER, 19.79, 127.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42432,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 58.88,,OUTPAT REV HCPCS COMBO 1, 65.88,OTHER, 19.79, 127.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42433,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 63.86,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42434,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 63.86,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42435,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 63.86,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42436,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 63.86,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42437,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 63.94,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42438,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 63.86,,OUTPAT REV HCPCS COMBO 1, 75.23,OTHER, 25.82, 138.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42439,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 54.56,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42440,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 50.87,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42441,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 71.79,,OUTPAT REV HCPCS COMBO 1, 68.02,OTHER, 17.35, 155.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42442,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 109.79,,OUTPAT REV HCPCS COMBO 1, 120.82,OTHER, 17.35, 238.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42443,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 105.99,,OUTPAT REV HCPCS COMBO 1, 120.82,OTHER, 17.35, 238.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42444,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 11.29,,OUTPAT REV HCPCS COMBO 1, 15.65,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42445,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.29,,OUTPAT REV HCPCS COMBO 1, 80.94,OTHER, 29.96, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42446,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.19,,OUTPAT REV HCPCS COMBO 1, 80.94,OTHER, 29.96, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42447,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 72.11,,OUTPAT REV HCPCS COMBO 1, 85.12,OTHER, 29.96, 156.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42448,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 89.05,,OUTPAT REV HCPCS COMBO 1, 103.45,OTHER, 29.96, 193.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42449,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 61.09,,OUTPAT REV HCPCS COMBO 1, 125.05,OTHER, 24.97, 345.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42450,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 159.15,,OUTPAT REV HCPCS COMBO 1, 125.05,OTHER, 24.97, 345.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42451,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 45.09,,OUTPAT REV HCPCS COMBO 1, 50.54,OTHER, 7.46, 97.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42452,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 75.09,,OUTPAT REV HCPCS COMBO 1, 88.87,OTHER, 32.17, 162.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42453,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 54.63,,OUTPAT REV HCPCS COMBO 1, 66.43,OTHER, 30.83, 118.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42454,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 48.32,,OUTPAT REV HCPCS COMBO 1, 57.43,OTHER, 21.72, 104.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42455,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 237.60,,OUTPAT REV HCPCS COMBO 1, 265.06,OTHER, 33.95, 515.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42456,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 66.37,,OUTPAT REV HCPCS COMBO 1, 80.97,OTHER, 38.57, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42457,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 66.37,,OUTPAT REV HCPCS COMBO 1, 80.97,OTHER, 38.57, 144.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42458,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 91.43,,OUTPAT REV HCPCS COMBO 1, 111.82,OTHER, 54.34, 198.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42459,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 148.05,,OUTPAT REV HCPCS COMBO 1, 176.22,OTHER, 67.64, 321.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42460,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 72.92,,OUTPAT REV HCPCS COMBO 1, 88.05,OTHER, 38.57, 158.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42461,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 72.92,,OUTPAT REV HCPCS COMBO 1, 88.05,OTHER, 38.57, 158.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42462,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 60.50,,OUTPAT REV HCPCS COMBO 1, 68.73,OTHER, 13.84, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42463,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 73.65,,OUTPAT REV HCPCS COMBO 1, 96.09,OTHER, 20.95, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42464,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 94.82,,OUTPAT REV HCPCS COMBO 1, 96.09,OTHER, 20.95, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42465,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 60.50,,OUTPAT REV HCPCS COMBO 1, 70.10,OTHER, 19.60, 131.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42466,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 41.53,,OUTPAT REV HCPCS COMBO 1, 46.86,OTHER, 8.16, 90.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42467,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 41.53,,OUTPAT REV HCPCS COMBO 1, 46.86,OTHER, 8.16, 90.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42468,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.57,,OUTPAT REV HCPCS COMBO 1, 191.67,OTHER, 89.24, 342.02,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42469,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 8.44,,OUTPAT REV HCPCS COMBO 1, 12.31,OTHER, 8.04, 18.33,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42470,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 15.76,,OUTPAT REV HCPCS COMBO 1, 18.56,OTHER, 6.34, 34.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42471,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 28.71,,OUTPAT REV HCPCS COMBO 1, 36.21,OTHER, 21.67, 62.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42472,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.86,,OUTPAT REV HCPCS COMBO 1, 55.25,OTHER, 14.66, 103.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42473,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.01,,OUTPAT REV HCPCS COMBO 1, 40.13,OTHER, 18.58, 71.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42474,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 57.34,,OUTPAT REV HCPCS COMBO 1, 66.54,OTHER, 19.00, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42475,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 76.32,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42476,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 76.32,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42477,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 76.32,,OUTPAT REV HCPCS COMBO 1, 88.38,OTHER, 24.53, 165.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42478,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 20.92,,OUTPAT REV HCPCS COMBO 1, 26.75,OTHER, 17.29, 45.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42479,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 43.76,,OUTPAT REV HCPCS COMBO 1, 91.08,OTHER, 16.51, 254.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42480,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 117.39,,OUTPAT REV HCPCS COMBO 1, 91.08,OTHER, 16.51, 254.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42481,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 42.44,,OUTPAT REV HCPCS COMBO 1, 50.83,OTHER, 20.72, 92.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42482,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 49.21,,OUTPAT REV HCPCS COMBO 1, 59.00,OTHER, 24.26, 106.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42483,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 54.75,,OUTPAT REV HCPCS COMBO 1, 64.46,OTHER, 22.02, 118.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42484,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 49.26,,OUTPAT REV HCPCS COMBO 1, 59.50,OTHER, 26.12, 106.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42485,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 49.26,,OUTPAT REV HCPCS COMBO 1, 59.50,OTHER, 26.12, 106.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42486,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 82.62,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42487,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 49.72,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42488,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 49.72,,OUTPAT REV HCPCS COMBO 1, 71.41,OTHER, 24.26, 179.32,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42489,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 55.53,,OUTPAT REV HCPCS COMBO 1, 66.70,OTHER, 27.86, 120.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42490,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 55.53,,OUTPAT REV HCPCS COMBO 1, 66.70,OTHER, 27.86, 120.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42491,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 35.67,,OUTPAT REV HCPCS COMBO 1, 43.51,OTHER, 20.72, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42492,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 39.90,,OUTPAT REV HCPCS COMBO 1, 47.68,OTHER, 19.00, 86.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42493,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.86,,OUTPAT REV HCPCS COMBO 1, 58.39,OTHER, 27.86, 103.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42494,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.26,,OUTPAT REV HCPCS COMBO 1, 77.47,OTHER, 19.86, 145.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42495,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 53.44,,OUTPAT REV HCPCS COMBO 1, 62.50,OTHER, 19.74, 116.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42496,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 39.40,,OUTPAT REV HCPCS COMBO 1, 46.75,OTHER, 17.35, 85.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42497,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 34.31,,OUTPAT REV HCPCS COMBO 1, 41.14,OTHER, 16.94, 74.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42498,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 58.62,,OUTPAT REV HCPCS COMBO 1, 67.08,OTHER, 15.47, 127.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42499,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 42.79,,OUTPAT REV HCPCS COMBO 1, 50.52,OTHER, 17.84, 92.87,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42500,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 22.48,,OUTPAT REV HCPCS COMBO 1, 28.18,OTHER, 16.21, 48.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42501,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 44.45,,OUTPAT REV HCPCS COMBO 1, 52.54,OTHER, 18.79, 96.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42502,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 44.45,,OUTPAT REV HCPCS COMBO 1, 52.54,OTHER, 18.79, 96.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42503,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.86,,OUTPAT REV HCPCS COMBO 1, 41.16,OTHER, 19.07, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42504,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.07,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42505,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.07,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42506,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.07,,OUTPAT REV HCPCS COMBO 1, 46.11,OTHER, 20.72, 82.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42507,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 39.39,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42508,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 40.75,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42509,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 40.75,,OUTPAT REV HCPCS COMBO 1, 48.00,OTHER, 18.55, 88.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42510,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 41.46,,OUTPAT REV HCPCS COMBO 1, 49.38,OTHER, 19.07, 89.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42511,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.99,,OUTPAT REV HCPCS COMBO 1, 80.11,OTHER, 18.55, 151.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42512,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.99,,OUTPAT REV HCPCS COMBO 1, 80.11,OTHER, 18.55, 151.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42513,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 330.40,,OUTPAT REV HCPCS COMBO 1, 361.76,OTHER, 18.55, 717.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42514,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 144.93,,OUTPAT REV HCPCS COMBO 1, 161.64,OTHER, 20.54, 314.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42515,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 126.32,,OUTPAT REV HCPCS COMBO 1, 158.63,OTHER, 92.44, 274.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42516,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 126.32,,OUTPAT REV HCPCS COMBO 1, 158.63,OTHER, 92.44, 274.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42517,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.03,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42518,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.03,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42519,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.03,,OUTPAT REV HCPCS COMBO 1, 78.01,OTHER, 14.06, 149.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42520,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 107.91,,OUTPAT REV HCPCS COMBO 1, 152.44,OTHER, 102.77, 234.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42521,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 194.53,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42522,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 194.53,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42523,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 194.53,,OUTPAT REV HCPCS COMBO 1, 270.23,OTHER, 185.27, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42524,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 73.89,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42525,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 73.89,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42526,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 73.89,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42527,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 73.89,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42528,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 73.89,,OUTPAT REV HCPCS COMBO 1, 81.76,OTHER, 7.76, 160.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42529,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 134.15,,OUTPAT REV HCPCS COMBO 1, 146.86,OTHER, 7.46, 291.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42530,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 49.67,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42531,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 49.67,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42532,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 49.67,,OUTPAT REV HCPCS COMBO 1, 54.74,OTHER, 4.31, 107.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42533,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 41.12,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42534,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 39.08,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42535,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 41.12,,OUTPAT REV HCPCS COMBO 1, 44.77,OTHER, 4.31, 89.26,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42536,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 194.53,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42537,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 194.53,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42538,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 176.76,,OUTPAT REV HCPCS COMBO 1, 205.30,OTHER, 5.52, 422.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42539,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 62.98,,OUTPAT REV HCPCS COMBO 1, 70.78,OTHER, 11.16, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42540,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 62.98,,OUTPAT REV HCPCS COMBO 1, 70.78,OTHER, 11.16, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42541,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 268.29,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42542,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 268.29,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42543,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 268.29,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42544,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 268.29,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42545,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 268.29,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42546,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 268.29,,OUTPAT REV HCPCS COMBO 1, 325.90,OTHER, 150.08, 582.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42547,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 62.98,,OUTPAT REV HCPCS COMBO 1, 76.50,OTHER, 35.20, 136.71,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42548,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 117.84,,OUTPAT REV HCPCS COMBO 1, 149.18,OTHER, 91.25, 255.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42549,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 72.00,,OUTPAT REV HCPCS COMBO 1, 81.41,OTHER, 14.86, 156.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42550,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 72.00,,OUTPAT REV HCPCS COMBO 1, 81.41,OTHER, 14.86, 156.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42551,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 25.45,,OUTPAT REV HCPCS COMBO 1, 30.76,OTHER, 13.60, 55.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42552,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 64.43,,OUTPAT REV HCPCS COMBO 1, 72.64,OTHER, 12.41, 139.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42553,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 64.43,,OUTPAT REV HCPCS COMBO 1, 72.64,OTHER, 12.41, 139.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42554,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.36,,OUTPAT REV HCPCS COMBO 1, 78.26,OTHER, 13.63, 150.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42555,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.36,,OUTPAT REV HCPCS COMBO 1, 78.26,OTHER, 13.63, 150.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42556,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 70.47,,OUTPAT REV HCPCS COMBO 1, 78.99,OTHER, 11.64, 152.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42557,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 40.68,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42558,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 40.68,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42559,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 40.68,,OUTPAT REV HCPCS COMBO 1, 46.77,OTHER, 11.64, 88.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42560,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 35.77,,OUTPAT REV HCPCS COMBO 1, 40.96,OTHER, 9.55, 77.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42561,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.75,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42562,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.75,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42563,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.75,,OUTPAT REV HCPCS COMBO 1, 44.68,OTHER, 11.62, 84.11,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42564,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 73.50,,OUTPAT REV HCPCS COMBO 1, 82.26,OTHER, 11.65, 159.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42565,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 73.50,,OUTPAT REV HCPCS COMBO 1, 82.26,OTHER, 11.65, 159.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42566,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 66.44,,OUTPAT REV HCPCS COMBO 1, 74.74,OTHER, 12.11, 144.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42567,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 80.72,,OUTPAT REV HCPCS COMBO 1, 91.00,OTHER, 15.55, 175.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42568,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 60.34,,OUTPAT REV HCPCS COMBO 1, 68.31,OTHER, 12.82, 130.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42569,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 14.90,,OUTPAT REV HCPCS COMBO 1, 17.74,OTHER, 6.84, 32.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42570,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 18.89,,OUTPAT REV HCPCS COMBO 1, 22.99,OTHER, 10.78, 40.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42571,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 26.19,,OUTPAT REV HCPCS COMBO 1, 29.95,OTHER, 6.84, 56.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42572,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 36.47,,OUTPAT REV HCPCS COMBO 1, 42.41,OTHER, 12.46, 79.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42573,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 25.55,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42574,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 23.79,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42575,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 23.79,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42576,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 23.88,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42577,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 23.88,,OUTPAT REV HCPCS COMBO 1, 27.61,OTHER, 6.14, 55.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42578,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.56,,OUTPAT REV HCPCS COMBO 1, 38.14,OTHER, 7.76, 72.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42579,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.56,,OUTPAT REV HCPCS COMBO 1, 38.14,OTHER, 7.76, 72.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42580,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 24.31,,OUTPAT REV HCPCS COMBO 1, 28.29,OTHER, 8.38, 52.77,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42581,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 57.34,,OUTPAT REV HCPCS COMBO 1, 68.72,OTHER, 28.16, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42582,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 273.02,,OUTPAT REV HCPCS COMBO 1, 299.39,OTHER, 17.26, 592.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42583,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 34.32,,OUTPAT REV HCPCS COMBO 1, 40.67,OTHER, 14.88, 74.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42584,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 36.17,,OUTPAT REV HCPCS COMBO 1, 43.08,OTHER, 16.61, 78.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42585,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 107.91,,OUTPAT REV HCPCS COMBO 1, 121.25,OTHER, 19.08, 234.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42586,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 57.34,,OUTPAT REV HCPCS COMBO 1, 68.89,OTHER, 28.87, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42587,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 87.14,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42588,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 87.14,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42589,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 87.14,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42590,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 87.14,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42591,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 87.14,,OUTPAT REV HCPCS COMBO 1, 107.02,OTHER, 53.66, 189.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42592,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 170.28,,OUTPAT REV HCPCS COMBO 1, 198.86,OTHER, 61.69, 369.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42593,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 170.28,,OUTPAT REV HCPCS COMBO 1, 198.86,OTHER, 61.69, 369.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42594,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 70.94,,OUTPAT REV HCPCS COMBO 1, 100.71,OTHER, 67.57, 153.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42595,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 191.20,,OUTPAT REV HCPCS COMBO 1, 221.47,OTHER, 61.69, 415.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42596,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 59.55,,OUTPAT REV HCPCS COMBO 1, 76.43,OTHER, 50.53, 129.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42597,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 218.07,,OUTPAT REV HCPCS COMBO 1, 265.03,OTHER, 122.54, 473.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42598,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 87.14,,OUTPAT REV HCPCS COMBO 1, 106.28,OTHER, 50.53, 189.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42599,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.73,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42600,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.73,,OUTPAT REV HCPCS COMBO 1, 96.14,OTHER, 64.50, 147.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42601,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 279.96,,OUTPAT REV HCPCS COMBO 1, 445.68,OTHER, 266.63, 607.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42602,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 45.15,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42603,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 45.15,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42604,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 45.15,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42605,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 168.24,,OUTPAT REV HCPCS COMBO 1, 193.99,OTHER, 50.53, 365.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42606,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 168.24,,OUTPAT REV HCPCS COMBO 1, 193.99,OTHER, 50.53, 365.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42607,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42608,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 149.45,,OUTPAT REV HCPCS COMBO 1, 173.66,OTHER, 50.53, 324.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42609,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 57.34,,OUTPAT REV HCPCS COMBO 1, 68.89,OTHER, 28.87, 124.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42610,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 79.10,,OUTPAT REV HCPCS COMBO 1, 204.22,OTHER, 50.53, 599.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42611,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 276.29,,OUTPAT REV HCPCS COMBO 1, 204.22,OTHER, 50.53, 599.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42612,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 121.89,,OUTPAT REV HCPCS COMBO 1, 146.52,OTHER, 61.69, 264.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42613,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 121.89,,OUTPAT REV HCPCS COMBO 1, 146.52,OTHER, 61.69, 264.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42614,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 52.32,,OUTPAT REV HCPCS COMBO 1, 62.25,OTHER, 23.83, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42615,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 52.32,,OUTPAT REV HCPCS COMBO 1, 62.25,OTHER, 23.83, 113.55,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42616,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 35.67,,OUTPAT REV HCPCS COMBO 1, 43.07,OTHER, 18.86, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42617,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 35.67,,OUTPAT REV HCPCS COMBO 1, 43.07,OTHER, 18.86, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42618,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 35.67,,OUTPAT REV HCPCS COMBO 1, 44.25,OTHER, 23.81, 77.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42619,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 11.29,,OUTPAT REV HCPCS COMBO 1, 17.88,OTHER, 10.75, 24.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42620,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 87.50,,OUTPAT REV HCPCS COMBO 1, 100.14,OTHER, 23.14, 189.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42621,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 658.74,,OUTPAT REV HCPCS COMBO 1, 800.72,OTHER, 370.73, 1429.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42622,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 658.74,,OUTPAT REV HCPCS COMBO 1, 800.72,OTHER, 370.73, 1429.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42623,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 46.96,,OUTPAT REV HCPCS COMBO 1, 59.91,OTHER, 38.32, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42624,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 46.96,,OUTPAT REV HCPCS COMBO 1, 59.91,OTHER, 38.32, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42625,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 250.58,,OUTPAT REV HCPCS COMBO 1, 294.34,OTHER, 97.97, 543.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42626,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42627,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42628,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 14.00,,OUTPAT REV HCPCS COMBO 1, 16.75,OTHER, 6.79, 30.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42629,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 14.00,,OUTPAT REV HCPCS COMBO 1, 16.75,OTHER, 6.79, 30.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42630,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 50.75,,OUTPAT REV HCPCS COMBO 1, 56.81,OTHER, 8.06, 110.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42631,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 34.64,,OUTPAT REV HCPCS COMBO 1, 39.98,OTHER, 10.56, 75.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42632,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 34.77,,OUTPAT REV HCPCS COMBO 1, 41.73,OTHER, 17.35, 75.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42633,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2678.49,,OUTPAT REV HCPCS COMBO 1, 3802.17,OTHER, 2550.94, 5813.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42634,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 50.87,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42635,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 50.87,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42636,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 13.32,,OUTPAT REV HCPCS COMBO 1, 23.30,OTHER, 12.69, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42637,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 26.86,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42638,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 13.43,,OUTPAT REV HCPCS COMBO 1, 23.42,OTHER, 12.79, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42639,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 58.24,,OUTPAT REV HCPCS COMBO 1, 82.68,OTHER, 55.47, 126.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42640,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42641,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.08,,OUTPAT REV HCPCS COMBO 1, 149.84,OTHER, 65.79, 315.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42642,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.08,,OUTPAT REV HCPCS COMBO 1, 149.84,OTHER, 65.79, 315.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42643,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 62.74,,OUTPAT REV HCPCS COMBO 1, 89.06,OTHER, 59.75, 136.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42644,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 22.58,,OUTPAT REV HCPCS COMBO 1, 41.40,OTHER, 21.50, 71.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42645,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 22.58,,OUTPAT REV HCPCS COMBO 1, 41.40,OTHER, 21.50, 71.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42646,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 267.92,,OUTPAT REV HCPCS COMBO 1, 356.50,OTHER, 255.16, 581.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42647,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 559.77,,OUTPAT REV HCPCS COMBO 1, 687.64,OTHER, 345.38, 1214.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42648,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 142.00,,OUTPAT REV HCPCS COMBO 1, 201.57,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42649,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42650,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42651,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.38,,OUTPAT REV HCPCS COMBO 1, 60.00,OTHER, 36.55, 83.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42652,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 23.23,,OUTPAT REV HCPCS COMBO 1, 36.74,OTHER, 22.12, 50.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42653,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 23.23,,OUTPAT REV HCPCS COMBO 1, 36.74,OTHER, 22.12, 50.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42654,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42655,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42656,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42657,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 4.97,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42658,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 4.97,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42659,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 4.97,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42660,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 4.97,,OUTPAT REV HCPCS COMBO 1, 7.05,OTHER, 4.73, 10.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42661,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 36.00,,OUTPAT REV HCPCS COMBO 1, 51.11,OTHER, 34.29, 78.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42662,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 61.72,,OUTPAT REV HCPCS COMBO 1, 87.62,OTHER, 58.79, 133.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42663,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 61.72,,OUTPAT REV HCPCS COMBO 1, 87.62,OTHER, 58.79, 133.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42664,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42665,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 71.25,,OUTPAT REV HCPCS COMBO 1, 111.30,OTHER, 67.85, 154.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42666,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 71.25,,OUTPAT REV HCPCS COMBO 1, 111.30,OTHER, 67.85, 154.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42667,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42668,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42669,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 77.17,,OUTPAT REV HCPCS COMBO 1, 104.75,OTHER, 73.49, 167.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42670,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 77.17,,OUTPAT REV HCPCS COMBO 1, 104.75,OTHER, 73.49, 167.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42671,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 4.52,,OUTPAT REV HCPCS COMBO 1, 12.78,OTHER, 4.30, 33.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42672,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 14.93,,OUTPAT REV HCPCS COMBO 1, 17.36,OTHER, 5.09, 32.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42673,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 137.22,,OUTPAT REV HCPCS COMBO 1, 184.48,OTHER, 130.68, 297.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42674,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 153.74,,OUTPAT REV HCPCS COMBO 1, 202.35,OTHER, 146.42, 333.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42675,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 66.79,,OUTPAT REV HCPCS COMBO 1, 99.37,OTHER, 63.61, 144.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42676,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 68.66,,OUTPAT REV HCPCS COMBO 1, 88.44,OTHER, 59.56, 149.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42677,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 88.44,,OUTPAT REV HCPCS COMBO 1, 131.72,OTHER, 84.22, 191.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42678,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 86.95,,OUTPAT REV HCPCS COMBO 1, 117.05,OTHER, 82.81, 188.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42679,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 132.84,,OUTPAT REV HCPCS COMBO 1, 179.75,OTHER, 126.51, 288.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42680,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 114.93,,OUTPAT REV HCPCS COMBO 1, 158.52,OTHER, 109.46, 249.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42681,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 138.81,,OUTPAT REV HCPCS COMBO 1, 186.21,OTHER, 132.20, 301.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42682,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 66.42,,OUTPAT REV HCPCS COMBO 1, 83.96,OTHER, 50.93, 144.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42683,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 107.10,,OUTPAT REV HCPCS COMBO 1, 167.44,OTHER, 102.00, 232.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42684,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 111.57,,OUTPAT REV HCPCS COMBO 1, 172.28,OTHER, 106.26, 242.17,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42685,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 26.87,,OUTPAT REV HCPCS COMBO 1, 49.86,OTHER, 25.59, 87.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42686,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 111.94,,OUTPAT REV HCPCS COMBO 1, 141.43,OTHER, 85.51, 242.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42687,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.69,,OUTPAT REV HCPCS COMBO 1, 69.71,OTHER, 45.42, 103.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42688,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 126.50,,OUTPAT REV HCPCS COMBO 1, 177.65,OTHER, 120.47, 274.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42689,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 137.41,,OUTPAT REV HCPCS COMBO 1, 189.46,OTHER, 130.87, 298.25,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42690,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 221.06,,OUTPAT REV HCPCS COMBO 1, 279.93,OTHER, 171.54, 479.83,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42691,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 207.26,,OUTPAT REV HCPCS COMBO 1, 265.00,OTHER, 171.54, 449.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42692,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 113.59,,OUTPAT REV HCPCS COMBO 1, 149.90,OTHER, 108.18, 246.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42693,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 144.28,,OUTPAT REV HCPCS COMBO 1, 167.02,OTHER, 46.09, 313.16,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42694,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 60.22,,OUTPAT REV HCPCS COMBO 1, 76.10,OTHER, 46.09, 130.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42695,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 126.09,,OUTPAT REV HCPCS COMBO 1, 147.35,OTHER, 46.09, 273.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42696,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 182.72,,OUTPAT REV HCPCS COMBO 1, 227.22,OTHER, 124.32, 396.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42697,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 245.84,,OUTPAT REV HCPCS COMBO 1, 295.49,OTHER, 124.32, 533.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42698,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 78.40,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 74.67, 170.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42699,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 116.39,,OUTPAT REV HCPCS COMBO 1, 155.48,OTHER, 110.85, 252.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42700,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 18.04,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42701,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 18.04,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42702,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 18.04,,OUTPAT REV HCPCS COMBO 1, 25.61,OTHER, 17.18, 39.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42703,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 8.83,,OUTPAT REV HCPCS COMBO 1, 36.72,OTHER, 8.41, 114.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42704,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 166.31,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 114.13, 360.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42705,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 166.31,,OUTPAT REV HCPCS COMBO 1, 207.04,OTHER, 114.13, 360.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42706,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 410.70,,OUTPAT REV HCPCS COMBO 1, 526.62,OTHER, 346.21, 891.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42707,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42708,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42709,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 139.06,,OUTPAT REV HCPCS COMBO 1, 162.12,OTHER, 49.24, 301.84,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42710,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 111.97,,OUTPAT REV HCPCS COMBO 1, 140.39,OTHER, 80.99, 243.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42711,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 111.97,,OUTPAT REV HCPCS COMBO 1, 140.39,OTHER, 80.99, 243.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42712,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 143.13,,OUTPAT REV HCPCS COMBO 1, 166.97,OTHER, 51.13, 310.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42713,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 39.56,,OUTPAT REV HCPCS COMBO 1, 54.96,OTHER, 37.67, 85.86,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42714,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 68.66,,OUTPAT REV HCPCS COMBO 1, 86.43,OTHER, 51.13, 149.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42715,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 734.45,,OUTPAT REV HCPCS COMBO 1, 950.56,OTHER, 656.16, 1594.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42716,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42717,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 419.90,,OUTPAT REV HCPCS COMBO 1, 545.72,OTHER, 384.68, 911.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42718,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 419.90,,OUTPAT REV HCPCS COMBO 1, 545.72,OTHER, 384.68, 911.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42719,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42720,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42721,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 497.67,,OUTPAT REV HCPCS COMBO 1, 591.97,OTHER, 225.62, 1080.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42722,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42723,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 210.26,,OUTPAT REV HCPCS COMBO 1, 250.40,OTHER, 96.59, 456.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42724,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 210.26,,OUTPAT REV HCPCS COMBO 1, 250.40,OTHER, 96.59, 456.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42725,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42726,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 471.49,,OUTPAT REV HCPCS COMBO 1, 563.65,OTHER, 225.62, 1023.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42727,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42728,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 73.59,,OUTPAT REV HCPCS COMBO 1, 113.30,OTHER, 70.09, 159.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42729,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 73.59,,OUTPAT REV HCPCS COMBO 1, 113.30,OTHER, 70.09, 159.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42730,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42731,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42732,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 225.75,,OUTPAT REV HCPCS COMBO 1, 297.88,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42733,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42734,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 211.19,,OUTPAT REV HCPCS COMBO 1, 262.11,OTHER, 141.55, 458.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42735,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 211.19,,OUTPAT REV HCPCS COMBO 1, 262.11,OTHER, 141.55, 458.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42736,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42737,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42738,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 573.16,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42739,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 573.16,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42740,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 304.53,,OUTPAT REV HCPCS COMBO 1, 383.08,OTHER, 225.62, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42741,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 573.16,,OUTPAT REV HCPCS COMBO 1, 673.61,OTHER, 225.62, 1244.07,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42742,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42743,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42744,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42745,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42746,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 304.53,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42747,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 304.53,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42748,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 304.53,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42749,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 304.53,,OUTPAT REV HCPCS COMBO 1, 363.06,OTHER, 141.55, 660.99,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42750,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42751,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42752,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42753,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42754,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 556.31,,OUTPAT REV HCPCS COMBO 1, 655.39,OTHER, 225.62, 1207.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42755,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42756,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1169.84,,OUTPAT REV HCPCS COMBO 1, 1042.14,OTHER, 284.89, 2539.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42757,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 631.87,,OUTPAT REV HCPCS COMBO 1, 1042.14,OTHER, 284.89, 2539.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42758,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 196.85,,OUTPAT REV HCPCS COMBO 1, 184.77,OTHER, 39.56, 427.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42759,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 41.54,,OUTPAT REV HCPCS COMBO 1, 184.77,OTHER, 39.56, 427.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42760,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 475.60,,OUTPAT REV HCPCS COMBO 1, 547.41,OTHER, 138.71, 1032.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42761,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 109.08,,OUTPAT REV HCPCS COMBO 1, 154.36,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42762,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 109.08,,OUTPAT REV HCPCS COMBO 1, 154.36,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42763,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 132.08,,OUTPAT REV HCPCS COMBO 1, 199.86,OTHER, 125.79, 286.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42764,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 132.08,,OUTPAT REV HCPCS COMBO 1, 199.86,OTHER, 125.79, 286.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42765,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 276.49,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42766,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 362.55,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42767,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 398.22,,OUTPAT REV HCPCS COMBO 1, 407.38,OTHER, 140.42, 864.36,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42768,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 276.49,,OUTPAT REV HCPCS COMBO 1, 332.46,OTHER, 140.42, 600.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42769,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 168.30,,OUTPAT REV HCPCS COMBO 1, 239.03,OTHER, 160.29, 365.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42770,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 168.30,,OUTPAT REV HCPCS COMBO 1, 239.03,OTHER, 160.29, 365.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42771,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 109.08,,OUTPAT REV HCPCS COMBO 1, 174.98,OTHER, 103.88, 239.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42772,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 109.08,,OUTPAT REV HCPCS COMBO 1, 136.10,OTHER, 76.16, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42773,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 78.11,,OUTPAT REV HCPCS COMBO 1, 140.33,OTHER, 74.39, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42774,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 191.89,,OUTPAT REV HCPCS COMBO 1, 228.33,OTHER, 87.35, 416.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42775,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 24.08,,OUTPAT REV HCPCS COMBO 1, 34.19,OTHER, 22.94, 52.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42776,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 46.96,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42777,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 147.93,,OUTPAT REV HCPCS COMBO 1, 182.46,OTHER, 94.34, 321.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42778,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 147.93,,OUTPAT REV HCPCS COMBO 1, 182.46,OTHER, 94.34, 321.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42779,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 64.76,,OUTPAT REV HCPCS COMBO 1, 125.89,OTHER, 61.67, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42780,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 64.76,,OUTPAT REV HCPCS COMBO 1, 125.89,OTHER, 61.67, 234.58,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42781,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 332.39,,OUTPAT REV HCPCS COMBO 1, 415.63,OTHER, 235.80, 721.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42782,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1467.38,,OUTPAT REV HCPCS COMBO 1, 1853.96,OTHER, 1121.15, 3185.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42783,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1467.38,,OUTPAT REV HCPCS COMBO 1, 1853.96,OTHER, 1121.15, 3185.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42784,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1760.85,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42785,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1760.85,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42786,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1760.85,,OUTPAT REV HCPCS COMBO 1, 2171.37,OTHER, 1121.15, 3822.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42787,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 122.46,,OUTPAT REV HCPCS COMBO 1, 152.82,OTHER, 85.61, 265.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42788,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 133.77,,OUTPAT REV HCPCS COMBO 1, 165.98,OTHER, 89.47, 290.35,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42789,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 216.84,,OUTPAT REV HCPCS COMBO 1, 260.74,OTHER, 110.12, 470.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42790,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 216.84,,OUTPAT REV HCPCS COMBO 1, 260.74,OTHER, 110.12, 470.66,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42791,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 81.36,,OUTPAT REV HCPCS COMBO 1, 96.89,OTHER, 37.34, 176.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42792,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 81.36,,OUTPAT REV HCPCS COMBO 1, 96.89,OTHER, 37.34, 176.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42793,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 258.10,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42794,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 258.10,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42795,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 258.10,,OUTPAT REV HCPCS COMBO 1, 323.07,OTHER, 184.46, 560.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42796,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 74.36,,OUTPAT REV HCPCS COMBO 1, 89.33,OTHER, 37.34, 161.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42797,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 74.39,,OUTPAT REV HCPCS COMBO 1, 89.33,OTHER, 37.34, 161.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42798,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 88.69,,OUTPAT REV HCPCS COMBO 1, 108.89,OTHER, 54.48, 192.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42799,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 88.69,,OUTPAT REV HCPCS COMBO 1, 108.89,OTHER, 54.48, 192.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42800,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 64.99,,OUTPAT REV HCPCS COMBO 1, 92.25,OTHER, 61.89, 141.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42801,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 64.99,,OUTPAT REV HCPCS COMBO 1, 92.25,OTHER, 61.89, 141.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42802,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.48,,OUTPAT REV HCPCS COMBO 1, 84.04,OTHER, 37.34, 150.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42803,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.48,,OUTPAT REV HCPCS COMBO 1, 84.04,OTHER, 37.34, 150.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42804,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 26.86,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42805,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 26.86,,OUTPAT REV HCPCS COMBO 1, 37.95,OTHER, 25.59, 58.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42806,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 135.83,,OUTPAT REV HCPCS COMBO 1, 159.88,OTHER, 54.48, 294.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42807,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 135.83,,OUTPAT REV HCPCS COMBO 1, 159.88,OTHER, 54.48, 294.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42808,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 77.17,,OUTPAT REV HCPCS COMBO 1, 96.44,OTHER, 54.48, 167.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42809,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 77.17,,OUTPAT REV HCPCS COMBO 1, 96.44,OTHER, 54.48, 167.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42810,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 77.88,,OUTPAT REV HCPCS COMBO 1, 110.56,OTHER, 74.18, 169.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42811,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 77.88,,OUTPAT REV HCPCS COMBO 1, 110.56,OTHER, 74.18, 169.05,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42812,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 39.71,,OUTPAT REV HCPCS COMBO 1, 47.95,OTHER, 21.01, 86.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42813,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 39.71,,OUTPAT REV HCPCS COMBO 1, 47.95,OTHER, 21.01, 86.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42814,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 43.59,,OUTPAT REV HCPCS COMBO 1, 55.33,OTHER, 34.39, 94.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42815,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 43.59,,OUTPAT REV HCPCS COMBO 1, 55.33,OTHER, 34.39, 94.61,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42816,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.76,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42817,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.76,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42818,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.76,,OUTPAT REV HCPCS COMBO 1, 58.74,OTHER, 29.74, 103.67,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42819,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 189.63,,OUTPAT REV HCPCS COMBO 1, 142.33,OTHER, 28.82, 411.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42820,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 60.88,,OUTPAT REV HCPCS COMBO 1, 142.33,OTHER, 28.82, 411.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42821,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 60.88,,OUTPAT REV HCPCS COMBO 1, 72.71,OTHER, 28.82, 132.15,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42822,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 55.48,,OUTPAT REV HCPCS COMBO 1, 74.33,OTHER, 52.80, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42823,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 55.44,,OUTPAT REV HCPCS COMBO 1, 74.33,OTHER, 52.80, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42824,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 55.48,,OUTPAT REV HCPCS COMBO 1, 74.35,OTHER, 52.84, 120.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42825,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 59.17,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42826,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 59.17,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42827,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 59.17,,OUTPAT REV HCPCS COMBO 1, 80.43,OTHER, 56.36, 128.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42828,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 42.95,,OUTPAT REV HCPCS COMBO 1, 60.80,OTHER, 40.91, 93.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42829,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 42.95,,OUTPAT REV HCPCS COMBO 1, 60.80,OTHER, 40.91, 93.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42830,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.53,,OUTPAT REV HCPCS COMBO 1, 47.68,OTHER, 29.08, 66.27,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42831,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 80.82,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42832,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 80.82,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42833,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 80.82,,OUTPAT REV HCPCS COMBO 1, 98.59,OTHER, 46.96, 175.42,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42834,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 97.07,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42835,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 97.07,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42836,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 97.07,,OUTPAT REV HCPCS COMBO 1, 115.67,OTHER, 44.87, 210.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42837,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 55.39,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42838,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 55.39,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42839,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 55.39,,OUTPAT REV HCPCS COMBO 1, 73.14,OTHER, 52.75, 120.22,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42840,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 19.87,,OUTPAT REV HCPCS COMBO 1, 30.33,OTHER, 18.92, 43.12,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42841,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 119.67,,OUTPAT REV HCPCS COMBO 1, 178.52,OTHER, 113.97, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42842,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 142.00,,OUTPAT REV HCPCS COMBO 1, 202.67,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42843,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 134.44,,OUTPAT REV HCPCS COMBO 1, 194.50,OTHER, 128.04, 291.81,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42844,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 66.98,,OUTPAT REV HCPCS COMBO 1, 106.37,OTHER, 63.79, 145.39,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42845,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 114.83,,OUTPAT REV HCPCS COMBO 1, 173.75,OTHER, 109.36, 249.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42846,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 121.38,,OUTPAT REV HCPCS COMBO 1, 180.83,OTHER, 115.60, 263.46,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42847,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 143.26,,OUTPAT REV HCPCS COMBO 1, 204.49,OTHER, 136.43, 310.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42848,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 69.19,,OUTPAT REV HCPCS COMBO 1, 108.91,OTHER, 65.89, 150.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42849,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 54.50,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42850,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 54.50,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42851,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 54.50,,OUTPAT REV HCPCS COMBO 1, 68.75,OTHER, 41.16, 118.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42852,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.14,,OUTPAT REV HCPCS COMBO 1, 44.69,OTHER, 31.56, 71.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42853,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 57.63,,OUTPAT REV HCPCS COMBO 1, 78.22,OTHER, 54.89, 125.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42854,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 57.63,,OUTPAT REV HCPCS COMBO 1, 78.22,OTHER, 54.89, 125.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42855,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 40.01,,OUTPAT REV HCPCS COMBO 1, 59.17,OTHER, 38.11, 86.85,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42856,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 52.37,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42857,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 52.37,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42858,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 52.37,,OUTPAT REV HCPCS COMBO 1, 66.10,OTHER, 39.73, 113.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42859,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42860,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 64.91,,OUTPAT REV HCPCS COMBO 1, 93.12,OTHER, 61.82, 140.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42861,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 54.63,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 52.03, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42862,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 119.67,,OUTPAT REV HCPCS COMBO 1, 114.40,OTHER, 52.03, 259.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42863,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 55.99,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42864,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 55.99,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42865,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 55.99,,OUTPAT REV HCPCS COMBO 1, 85.61,OTHER, 53.32, 121.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42866,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.86,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42867,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 46.96,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42868,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 63.66,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42869,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 46.96,,OUTPAT REV HCPCS COMBO 1, 66.66,OTHER, 44.72, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42870,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 63.66,,OUTPAT REV HCPCS COMBO 1, 90.37,OTHER, 60.63, 138.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42871,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.86,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42872,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.86,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42873,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 135.45,,OUTPAT REV HCPCS COMBO 1, 192.27,OTHER, 129.00, 294.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42874,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42875,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42876,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 109.08,,OUTPAT REV HCPCS COMBO 1, 145.27,OTHER, 103.88, 236.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42877,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.16,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42878,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.16,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42879,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 113.81,,OUTPAT REV HCPCS COMBO 1, 161.56,OTHER, 108.39, 247.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42880,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 113.81,,OUTPAT REV HCPCS COMBO 1, 161.56,OTHER, 108.39, 247.03,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42881,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 178.07,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42882,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 178.07,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42883,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 221.82,,OUTPAT REV HCPCS COMBO 1, 314.88,OTHER, 211.26, 481.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42884,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 221.82,,OUTPAT REV HCPCS COMBO 1, 314.88,OTHER, 211.26, 481.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42885,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 21.49,,OUTPAT REV HCPCS COMBO 1, 30.51,OTHER, 20.47, 46.65,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42886,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 46.82,,OUTPAT REV HCPCS COMBO 1, 66.46,OTHER, 44.59, 101.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42887,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 46.82,,OUTPAT REV HCPCS COMBO 1, 66.46,OTHER, 44.59, 101.63,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42888,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 78.29,,OUTPAT REV HCPCS COMBO 1, 111.13,OTHER, 74.56, 169.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42889,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 78.29,,OUTPAT REV HCPCS COMBO 1, 111.13,OTHER, 74.56, 169.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42890,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 115.52,,OUTPAT REV HCPCS COMBO 1, 163.98,OTHER, 110.02, 250.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42891,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 115.52,,OUTPAT REV HCPCS COMBO 1, 163.98,OTHER, 110.02, 250.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42892,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 154.66,,OUTPAT REV HCPCS COMBO 1, 219.55,OTHER, 147.30, 335.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42893,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 154.66,,OUTPAT REV HCPCS COMBO 1, 219.55,OTHER, 147.30, 335.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42894,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42895,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42896,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42897,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42898,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42899,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 121.42,,OUTPAT REV HCPCS COMBO 1, 149.74,OTHER, 77.35, 263.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42900,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 121.42,,OUTPAT REV HCPCS COMBO 1, 149.74,OTHER, 77.35, 263.54,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42901,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42902,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42903,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 187.82,,OUTPAT REV HCPCS COMBO 1, 233.57,OTHER, 127.82, 407.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42904,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 187.82,,OUTPAT REV HCPCS COMBO 1, 233.57,OTHER, 127.82, 407.68,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42905,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42906,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42907,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 296.79,,OUTPAT REV HCPCS COMBO 1, 369.55,OTHER, 203.96, 644.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42908,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 296.79,,OUTPAT REV HCPCS COMBO 1, 369.55,OTHER, 203.96, 644.19,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42909,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42910,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42911,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 465.53,,OUTPAT REV HCPCS COMBO 1, 580.80,OTHER, 324.71, 1010.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42912,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 465.53,,OUTPAT REV HCPCS COMBO 1, 580.80,OTHER, 324.71, 1010.45,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42913,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42914,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42915,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 776.48,,OUTPAT REV HCPCS COMBO 1, 954.02,OTHER, 479.76, 1685.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42916,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 776.48,,OUTPAT REV HCPCS COMBO 1, 954.02,OTHER, 479.76, 1685.38,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42917,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 42918,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1241.98,,OUTPAT REV HCPCS COMBO 1, 1514.86,OTHER, 720.78, 2695.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42919,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 455.30,,OUTPAT REV HCPCS COMBO 1, 646.30,OTHER, 433.62, 988.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42920,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 13.55,,OUTPAT REV HCPCS COMBO 1, 19.23,OTHER, 12.90, 29.40,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42921,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 75.60,,OUTPAT REV HCPCS COMBO 1, 107.32,OTHER, 72.00, 164.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42922,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 75.60,,OUTPAT REV HCPCS COMBO 1, 107.32,OTHER, 72.00, 164.10,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42923,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 118.97,,OUTPAT REV HCPCS COMBO 1, 167.97,OTHER, 113.31, 258.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42924,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 123.96,,OUTPAT REV HCPCS COMBO 1, 173.37,OTHER, 118.06, 269.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42925,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 129.33,,OUTPAT REV HCPCS COMBO 1, 179.18,OTHER, 123.17, 280.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42926,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 146.22,,OUTPAT REV HCPCS COMBO 1, 197.44,OTHER, 139.26, 317.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42927,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 142.00,,OUTPAT REV HCPCS COMBO 1, 192.88,OTHER, 135.24, 308.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42928,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 163.87,,OUTPAT REV HCPCS COMBO 1, 232.62,OTHER, 156.07, 355.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42929,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 178.07,,OUTPAT REV HCPCS COMBO 1, 252.78,OTHER, 169.59, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42930,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 107.07,,OUTPAT REV HCPCS COMBO 1, 155.10,OTHER, 101.97, 232.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42931,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 114.36,,OUTPAT REV HCPCS COMBO 1, 162.99,OTHER, 108.92, 248.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42932,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 124.73,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42933,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 124.73,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42934,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 124.73,,OUTPAT REV HCPCS COMBO 1, 174.20,OTHER, 118.79, 270.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42935,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 127.41,,OUTPAT REV HCPCS COMBO 1, 177.10,OTHER, 121.35, 276.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42936,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 135.86,,OUTPAT REV HCPCS COMBO 1, 192.85,OTHER, 129.39, 294.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42937,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 146.22,,OUTPAT REV HCPCS COMBO 1, 207.56,OTHER, 139.26, 317.37,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42938,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 39.15,,OUTPAT REV HCPCS COMBO 1, 55.57,OTHER, 37.28, 84.97,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42939,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.16,,OUTPAT REV HCPCS COMBO 1, 95.34,OTHER, 63.96, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42940,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 31.61,,OUTPAT REV HCPCS COMBO 1, 44.86,OTHER, 30.10, 68.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42941,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 120.12,,OUTPAT REV HCPCS COMBO 1, 170.52,OTHER, 114.40, 260.73,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42942,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 23.88,,OUTPAT REV HCPCS COMBO 1, 33.14,OTHER, 22.74, 51.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42943,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 29.55,,OUTPAT REV HCPCS COMBO 1, 39.28,OTHER, 28.14, 64.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42944,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 42.61,,OUTPAT REV HCPCS COMBO 1, 60.49,OTHER, 40.58, 92.49,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42945,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 9.93,,OUTPAT REV HCPCS COMBO 1, 14.10,OTHER, 9.46, 21.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42946,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 9.93,,OUTPAT REV HCPCS COMBO 1, 54.72,OTHER, 9.46, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42947,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 67.16,,OUTPAT REV HCPCS COMBO 1, 54.72,OTHER, 9.46, 145.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42948,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 115.13,,OUTPAT REV HCPCS COMBO 1, 148.65,OTHER, 101.33, 249.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42949,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 124.16,,OUTPAT REV HCPCS COMBO 1, 166.04,OTHER, 118.25, 269.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42950,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 5.76,,OUTPAT REV HCPCS COMBO 1, 8.17,OTHER, 5.48, 12.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42951,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 5.76,,OUTPAT REV HCPCS COMBO 1, 8.17,OTHER, 5.48, 12.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42952,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 173.83,,OUTPAT REV HCPCS COMBO 1, 350.13,OTHER, 165.55, 680.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42953,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 173.83,,OUTPAT REV HCPCS COMBO 1, 350.13,OTHER, 165.55, 680.93,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42954,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 274.06,,OUTPAT REV HCPCS COMBO 1, 553.11,OTHER, 261.01, 1078.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42955,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 274.06,,OUTPAT REV HCPCS COMBO 1, 553.11,OTHER, 261.01, 1078.14,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42956,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 160.28,,OUTPAT REV HCPCS COMBO 1, 308.45,OTHER, 152.65, 567.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42957,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 160.28,,OUTPAT REV HCPCS COMBO 1, 308.45,OTHER, 152.65, 567.43,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42958,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 231.17,,OUTPAT REV HCPCS COMBO 1, 466.19,OTHER, 220.16, 907.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42959,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 231.17,,OUTPAT REV HCPCS COMBO 1, 466.19,OTHER, 220.16, 907.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42960,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 396.42,,OUTPAT REV HCPCS COMBO 1, 562.72,OTHER, 377.54, 860.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42961,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 396.42,,OUTPAT REV HCPCS COMBO 1, 562.72,OTHER, 377.54, 860.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42962,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 440.21,,OUTPAT REV HCPCS COMBO 1, 624.89,OTHER, 419.25, 955.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42963,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 440.21,,OUTPAT REV HCPCS COMBO 1, 624.89,OTHER, 419.25, 955.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42964,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 61.40,,OUTPAT REV HCPCS COMBO 1, 87.16,OTHER, 58.48, 133.28,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42965,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 28.90,,OUTPAT REV HCPCS COMBO 1, 41.02,OTHER, 27.52, 62.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42966,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.86,,OUTPAT REV HCPCS COMBO 1, 48.07,OTHER, 32.25, 73.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42967,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1352.69,,OUTPAT REV HCPCS COMBO 1, 1648.47,OTHER, 779.04, 2936.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42968,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1352.69,,OUTPAT REV HCPCS COMBO 1, 1648.47,OTHER, 779.04, 2936.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42969,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1472.34,,OUTPAT REV HCPCS COMBO 1, 1777.88,OTHER, 779.04, 3195.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42970,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1472.34,,OUTPAT REV HCPCS COMBO 1, 1777.88,OTHER, 779.04, 3195.78,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42971,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1038.45,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42972,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1038.45,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42973,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1038.45,,OUTPAT REV HCPCS COMBO 1, 1244.21,OTHER, 508.57, 2254.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42974,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1097.72,OTHER, 508.57, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42975,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1097.72,OTHER, 508.57, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42976,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1162.11,OTHER, 779.04, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42977,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 903.00,,OUTPAT REV HCPCS COMBO 1, 1162.11,OTHER, 779.04, 1960.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42978,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 8.64,,OUTPAT REV HCPCS COMBO 1, 9.74,OTHER, 1.66, 18.76,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42979,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 50.87,,OUTPAT REV HCPCS COMBO 1, 63.90,OTHER, 37.34, 110.41,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42980,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2.71,,OUTPAT REV HCPCS COMBO 1, 11.82,OTHER, 2.58, 37.34,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42981,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 40.68,,OUTPAT REV HCPCS COMBO 1, 57.75,OTHER, 38.74, 88.30,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42982,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 21.11,,OUTPAT REV HCPCS COMBO 1, 29.96,OTHER, 20.10, 45.82,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42983,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 74.64,,OUTPAT REV HCPCS COMBO 1, 88.75,OTHER, 33.71, 162.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42984,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 46.96,,OUTPAT REV HCPCS COMBO 1, 58.81,OTHER, 33.71, 101.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42985,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 176.54,,OUTPAT REV HCPCS COMBO 1, 250.60,OTHER, 168.13, 383.18,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42986,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 178.07,,OUTPAT REV HCPCS COMBO 1, 231.89,OTHER, 165.06, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42987,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 178.07,,OUTPAT REV HCPCS COMBO 1, 231.89,OTHER, 165.06, 386.51,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42988,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 19.19,,OUTPAT REV HCPCS COMBO 1, 35.44,OTHER, 18.28, 61.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42989,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 27.63,,OUTPAT REV HCPCS COMBO 1, 44.57,OTHER, 26.32, 61.69,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42990,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.70,,OUTPAT REV HCPCS COMBO 1, 43.58,OTHER, 29.24, 66.64,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42991,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42992,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 117.30,,OUTPAT REV HCPCS COMBO 1, 166.51,OTHER, 111.71, 254.60,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42993,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 42.34,,OUTPAT REV HCPCS COMBO 1, 60.10,OTHER, 40.32, 91.89,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42994,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 3.47,,OUTPAT REV HCPCS COMBO 1, 4.92,OTHER, 3.30, 7.53,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42995,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 3.36,,OUTPAT REV HCPCS COMBO 1, 4.77,OTHER, 3.20, 7.29,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42996,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 9.17,,OUTPAT REV HCPCS COMBO 1, 13.02,OTHER, 8.74, 19.91,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42997,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 94.82,,OUTPAT REV HCPCS COMBO 1, 134.59,OTHER, 90.30, 205.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42998,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .96,,OUTPAT REV HCPCS COMBO 1, 1.36,OTHER, .91, 2.08,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 42999,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1.48,,OUTPAT REV HCPCS COMBO 1, 2.10,OTHER, 1.41, 3.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43000,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 18.25,,OUTPAT REV HCPCS COMBO 1, 25.91,OTHER, 17.38, 39.62,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43001,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 65.52,,OUTPAT REV HCPCS COMBO 1, 93.00,OTHER, 62.40, 142.21,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43002,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1.03,,OUTPAT REV HCPCS COMBO 1, 1.46,OTHER, .98, 2.23,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43003,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .72,,OUTPAT REV HCPCS COMBO 1, 1.03,OTHER, .69, 1.57,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43004,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 3.63,,OUTPAT REV HCPCS COMBO 1, 5.15,OTHER, 3.46, 7.88,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43005,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 8.07,,OUTPAT REV HCPCS COMBO 1, 11.46,OTHER, 7.69, 17.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43006,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 3.09,,OUTPAT REV HCPCS COMBO 1, 4.38,OTHER, 2.94, 6.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43007,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1.81,,OUTPAT REV HCPCS COMBO 1, 2.56,OTHER, 1.72, 3.92,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43008,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 5.27,,OUTPAT REV HCPCS COMBO 1, 7.91,OTHER, 5.02, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43009,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 5.87,,OUTPAT REV HCPCS COMBO 1, 7.91,OTHER, 5.02, 12.74,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43010,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.85,,OUTPAT REV HCPCS COMBO 1, 43.79,OTHER, 29.38, 66.95,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43011,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 16.22,,OUTPAT REV HCPCS COMBO 1, 23.02,OTHER, 15.45, 35.20,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43012,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 4.75,,OUTPAT REV HCPCS COMBO 1, 6.74,OTHER, 4.52, 10.31,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43013,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 3.67,,OUTPAT REV HCPCS COMBO 1, 5.20,OTHER, 3.49, 7.96,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43014,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 180.15,,OUTPAT REV HCPCS COMBO 1, 575.18,OTHER, 171.57, 1597.44,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43015,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 180.15,,OUTPAT REV HCPCS COMBO 1, 690.66,OTHER, 171.57, 2082.47,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43016,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 180.15,,OUTPAT REV HCPCS COMBO 1, 656.15,OTHER, 171.57, 1937.50,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43017,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 180.15,,OUTPAT REV HCPCS COMBO 1, 607.70,OTHER, 171.57, 1734.01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43018,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 225.30,,OUTPAT REV HCPCS COMBO 1, 735.35,OTHER, 214.57, 2065.06,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43019,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 386.03,,OUTPAT REV HCPCS COMBO 1, 421.89,OTHER, 18.42, 837.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43020,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2.17,,OUTPAT REV HCPCS COMBO 1, 3.08,OTHER, 2.06, 4.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43021,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43022,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43023,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43024,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43025,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43026,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43027,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43028,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43029,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43030,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43031,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43032,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 157.12,,OUTPAT REV HCPCS COMBO 1, 196.27,OTHER, 110.60, 341.04,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43033,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 187.37,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43034,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 187.37,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43035,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 187.37,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43036,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 187.37,,OUTPAT REV HCPCS COMBO 1, 251.75,OTHER, 178.45, 406.70,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43037,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43038,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43039,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43040,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43041,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43042,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43043,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43044,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43045,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43046,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43047,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43048,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43049,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43050,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43051,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43052,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43053,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43054,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43055,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43056,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 598.69,,OUTPAT REV HCPCS COMBO 1, 810.02,OTHER, 570.18, 1299.48,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43057,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.97,,OUTPAT REV HCPCS COMBO 1, 62.01,OTHER, 42.53, 104.13,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43058,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 51.47,,OUTPAT REV HCPCS COMBO 1, 73.06,OTHER, 49.02, 111.72,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43059,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 45.15,,OUTPAT REV HCPCS COMBO 1, 64.18,OTHER, 43.00, 98.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43060,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 225.75,,OUTPAT REV HCPCS COMBO 1, 320.46,OTHER, 215.00, 490.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43061,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 18.96,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43062,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1.35,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43063,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 15.80,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43064,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1.35,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43065,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 12.19,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43066,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1.35,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43067,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 6.77,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43068,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1.42,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43069,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.86,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43070,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1.42,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43071,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2.04,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43072,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 45.60,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43073,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2.71,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43074,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2.71,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43075,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 83.04,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43076,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2.71,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43077,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 81.27,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43078,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 26.19,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43079,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 26.19,,OUTPAT REV HCPCS COMBO 1, 27.42,OTHER, 1.29, 180.24,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43080,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 149.97,,OUTPAT REV HCPCS COMBO 1, 212.89,OTHER, 142.83, 325.52,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43081,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 54.99,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43082,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.86,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43083,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 444.56,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43084,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 323.74,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43085,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 4.06,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43086,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2.71,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43087,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 45.60,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43088,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 45.60,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43089,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 45.60,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43090,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 45.60,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43091,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 45.60,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43092,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 45.60,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43093,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 45.60,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43094,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2.71,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43095,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 45.60,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43096,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 46.05,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43097,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 32.44,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43098,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 32.44,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43099,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 33.86,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43100,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 62.12,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43101,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1.35,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43102,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 6.77,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43103,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 6.77,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43104,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 6.77,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43105,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 8.13,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43106,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 10.84,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43107,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1.35,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43108,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 12.88,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43109,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 12.88,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43110,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 13.55,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43111,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 13.55,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43112,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 13.55,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43113,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 13.55,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43114,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1.35,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43115,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1.35,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43116,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 20.99,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43117,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 4.52,,OUTPAT REV HCPCS COMBO 1, 60.94,OTHER, 1.29, 964.94,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43118,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1.42,,OUTPAT REV HCPCS COMBO 1, 2.02,OTHER, 1.35, 3.09,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43119,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 226.20,,OUTPAT REV HCPCS COMBO 1, 321.10,OTHER, 215.43, 490.98,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43120,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 258.26,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43121,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43122,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43123,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43124,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43125,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43126,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43127,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, 35.99,OTHER, .01, 560.56,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43128,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 15.36,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43129,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 68.71,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43130,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 64.40,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43131,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 42.08,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43132,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 38.62,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43133,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 117.52,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43134,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 3433.97,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43135,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 20.42,,OUTPAT REV HCPCS COMBO 1, 674.46,OTHER, 14.63, 7453.59,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43136,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43137,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43138,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43139,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43140,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43141,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43142,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 1083.60,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43143,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43144,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43145,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43146,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43147,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43148,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 803.67,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43149,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 632.10,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43150,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 632.10,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43151,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 632.10,,OUTPAT REV HCPCS COMBO 1, 1119.99,OTHER, 602.00, 2352.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43152,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43153,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43154,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43155,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 47.41,,OUTPAT REV HCPCS COMBO 1, 67.30,OTHER, 45.15, 102.90,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43156,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43157,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 30.31,,OUTPAT REV HCPCS COMBO 1, 43.03,OTHER, 28.87, 65.79,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43158,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 4.52,,OUTPAT REV HCPCS COMBO 1, 6.41,OTHER, 4.30, 9.80,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43159,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2618.70,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43160,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2167.20,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43161,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2167.20,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43162,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, 2167.20,,OUTPAT REV HCPCS COMBO 1, 3236.61,OTHER, 2064.00, 5684.00,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43163,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43164,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43165,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43166,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43167,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43168,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43169,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43170,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43171,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43172,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43173,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43174,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43175,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43176,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43177,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43178,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43179,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43180,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43181,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43182,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43183,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43184,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43185,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43186,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43187,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43188,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43189,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43190,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTERNSKY_MEDICARE,WESTERN SKY MEDICARE, .01,,OUTPAT REV HCPCS COMBO 1, .01,OTHER, .01, .01,REVENUE HCPCS CODE COMBINATION CALCULATION WITH MULTIPLE OPTIONS FOR CACULATION REIMBURSEMENT 43191,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43192,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43193,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43194,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43195,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43196,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43197,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43198,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43199,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43200,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43201,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43202,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43203,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43204,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43205,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43206,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43207,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43208,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43209,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 271.70,OTHER, 142.76, 477.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43210,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 271.70,OTHER, 142.76, 477.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43211,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 168.89,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43212,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 171.36,OTHER, 103.33, 229.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43213,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 273.87,OTHER, 142.76, 481.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43214,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 142.76,,CLAIM ADJUSTMENT 3, 276.81,OTHER, 142.76, 430.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43215,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 274.44,,CLAIM ADJUSTMENT 3, 242.16,OTHER, 155.70, 354.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43216,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 850.02,OTHER, 203.58, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43217,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1237.88,,CLAIM ADJUSTMENT 3, 667.92,OTHER, 193.86, 1237.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43218,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 274.44,,CLAIM ADJUSTMENT 3, 177.23,OTHER, 68.01, 274.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43219,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 267.92,,CLAIM ADJUSTMENT 3, 131.69,OTHER, 30.91, 267.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43220,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 116.49,OTHER, 56.08, 143.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43221,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 256.74,,CLAIM ADJUSTMENT 3, 405.48,OTHER, 256.74, 597.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43222,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43223,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 256.74,,CLAIM ADJUSTMENT 3, 216.69,OTHER, 107.31, 256.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43224,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43225,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 456.98,,CLAIM ADJUSTMENT 3, 233.68,OTHER, 60.50, 456.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43226,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 158.67,OTHER, 92.29, 204.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43227,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 112.58,OTHER, 70.21, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43228,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 125.44,OTHER, 81.25, 180.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43229,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 114.17,OTHER, 51.67, 151.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43230,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 122.15,OTHER, 60.94, 143.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43231,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 138.81,OTHER, 86.20, 205.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43232,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 117.21,OTHER, 74.19, 164.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43233,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 258.26,OTHER, 90.53, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43234,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 287.58,OTHER, 115.70, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43235,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 334.39,OTHER, 155.88, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43236,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 1514.68,OTHER, 804.50, 2338.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43237,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 1306.30,OTHER, 595.28, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43238,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 925.64,OTHER, 268.49, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43239,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 389.69,OTHER, 87.88, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43240,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 427.24,OTHER, 120.12, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43241,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 457.59,OTHER, 146.17, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43242,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 732.74,OTHER, 102.89, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43243,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1168.49,OTHER, 299.85, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43244,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 300.44,OTHER, 126.74, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43245,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 495.14,OTHER, 178.41, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43246,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 534.75,OTHER, 212.41, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43247,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 572.81,OTHER, 245.09, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43248,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 541.95,OTHER, 218.59, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43249,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 578.99,OTHER, 250.39, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43250,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 1505.88,OTHER, 766.62, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43251,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 646.89,OTHER, 308.68, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43252,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1242.56,OTHER, 363.44, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43253,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 513.14,OTHER, 193.86, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43254,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 520.86,OTHER, 200.49, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43255,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 804.50,,CLAIM ADJUSTMENT 3, 694.73,OTHER, 349.75, 804.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43256,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 947.76,OTHER, 287.48, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43257,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1393.28,OTHER, 492.83, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43258,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 56.01,OTHER, 24.73, 76.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43259,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 185.53,OTHER, 86.20, 331.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43260,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 97.29,OTHER, 57.09, 126.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43261,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 97.14,OTHER, 56.97, 126.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43262,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 57.02,OTHER, 22.52, 86.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43263,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 427.86,,CLAIM ADJUSTMENT 3, 372.97,OTHER, 189.00, 427.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43264,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1446.78,OTHER, 538.75, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43265,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 1121.68,OTHER, 259.66, 2293.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43266,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 383.22,,CLAIM ADJUSTMENT 3, 278.63,OTHER, 165.01, 383.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43267,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 383.22,,CLAIM ADJUSTMENT 3, 427.61,OTHER, 296.20, 675.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43268,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 237.66,OTHER, 143.26, 408.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43269,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 253.66,OTHER, 143.26, 440.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43270,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 272.17,OTHER, 143.26, 477.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43271,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 251.39,OTHER, 143.26, 436.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43272,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 261.55,OTHER, 143.26, 400.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43273,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 143.26,,CLAIM ADJUSTMENT 3, 264.56,OTHER, 143.26, 462.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43274,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 306.35,OTHER, 204.98, 467.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43275,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 548.12,OTHER, 309.01, 833.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43276,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 132.82,,CLAIM ADJUSTMENT 3, 300.52,OTHER, 132.82, 482.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43277,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 132.82,,CLAIM ADJUSTMENT 3, 293.08,OTHER, 132.82, 524.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43278,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 1023.77,OTHER, 309.01, 1906.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43279,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 309.01,,CLAIM ADJUSTMENT 3, 498.22,OTHER, 309.01, 738.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43280,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 435.32,,CLAIM ADJUSTMENT 3, 1703.49,OTHER, 435.32, 3210.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43281,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 435.32,,CLAIM ADJUSTMENT 3, 601.46,OTHER, 382.87, 849.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43282,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2347.12,,CLAIM ADJUSTMENT 3, 2228.68,OTHER, 1193.64, 2648.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43283,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 2329.49,OTHER, 1296.54, 2877.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43284,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 274.44,,CLAIM ADJUSTMENT 3, 163.86,OTHER, 56.52, 274.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43285,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 200.99,OTHER, 145.30, 331.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43286,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.20,,CLAIM ADJUSTMENT 3, 93.03,OTHER, 53.43, 118.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43287,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 43.50,,CLAIM ADJUSTMENT 3, 22.22,OTHER, 5.74, 43.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43288,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 224.77,OTHER, 146.61, 325.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43289,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 451.07,,CLAIM ADJUSTMENT 3, 251.63,OTHER, 77.72, 451.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43290,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2427.54,,CLAIM ADJUSTMENT 3, 1148.36,OTHER, 241.56, 2427.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43291,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2427.54,,CLAIM ADJUSTMENT 3, 1534.16,OTHER, 572.76, 2427.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43292,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 232.01,OTHER, 122.32, 271.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43293,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 124.43,OTHER, 57.02, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43294,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 120.23,OTHER, 53.32, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43295,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 130.25,OTHER, 62.14, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43296,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 250.67,,CLAIM ADJUSTMENT 3, 130.25,OTHER, 62.14, 250.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43297,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2293.79,,CLAIM ADJUSTMENT 3, 5204.99,OTHER, 2293.79, 8355.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43298,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1716.08,,CLAIM ADJUSTMENT 3, 932.84,OTHER, 274.68, 1716.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43299,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 424.57,OTHER, 162.56, 774.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43300,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 334.89,OTHER, 162.56, 594.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43301,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 470.23,,CLAIM ADJUSTMENT 3, 675.88,OTHER, 470.23, 1131.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43302,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 499.77,OTHER, 162.56, 925.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43303,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 499.77,OTHER, 162.56, 925.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43304,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 207.69,OTHER, 148.80, 339.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43305,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 162.56,,CLAIM ADJUSTMENT 3, 207.69,OTHER, 148.80, 339.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43306,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 103.34,,CLAIM ADJUSTMENT 3, 176.70,OTHER, 103.34, 305.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43307,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 188.66,,CLAIM ADJUSTMENT 3, 596.69,OTHER, 188.66, 1107.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43308,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 188.66,,CLAIM ADJUSTMENT 3, 596.69,OTHER, 188.66, 1107.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43309,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 544.52,,CLAIM ADJUSTMENT 3, 1089.64,OTHER, 544.52, 1926.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43310,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43311,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43312,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43313,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43314,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43315,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 18.10,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43316,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.34,,CLAIM ADJUSTMENT 3, 20.38,OTHER, 12.34, 30.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43317,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43318,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 331.58,,CLAIM ADJUSTMENT 3, 579.04,OTHER, 331.58, 1003.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43319,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1095.12,,CLAIM ADJUSTMENT 3, 1525.88,OTHER, 974.17, 2161.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43320,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2484.68,,CLAIM ADJUSTMENT 3, 4097.24,OTHER, 2484.68, 6115.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43321,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2985.38,,CLAIM ADJUSTMENT 3, 4480.28,OTHER, 2930.90, 6504.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43322,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1095.12,,CLAIM ADJUSTMENT 3, 813.44,OTHER, 362.55, 1095.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43323,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1095.12,,CLAIM ADJUSTMENT 3, 4090.68,OTHER, 1095.12, 7048.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43324,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 26.22,,CLAIM ADJUSTMENT 3, 124.21,OTHER, 26.22, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43325,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 26.22,,CLAIM ADJUSTMENT 3, 124.21,OTHER, 26.22, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43326,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2414.09,,CLAIM ADJUSTMENT 3, 1187.28,OTHER, 279.09, 2414.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43327,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1685.72,,CLAIM ADJUSTMENT 3, 803.17,OTHER, 172.67, 1685.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43328,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1685.72,,CLAIM ADJUSTMENT 3, 1733.21,OTHER, 971.08, 2155.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43329,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 1757.99,OTHER, 857.80, 2765.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43330,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 477.65,OTHER, 147.05, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43331,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 497.71,OTHER, 164.28, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43332,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 1514.68,OTHER, 857.80, 2302.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43333,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 2013.65,OTHER, 857.80, 3252.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43334,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 549.67,OTHER, 208.88, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43335,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 857.80,,CLAIM ADJUSTMENT 3, 578.48,OTHER, 233.61, 857.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43336,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43337,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43338,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 625.15,,CLAIM ADJUSTMENT 3, 718.33,OTHER, 501.48, 1142.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43339,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43340,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2666.24,,CLAIM ADJUSTMENT 3, 1780.93,OTHER, 711.42, 2666.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43341,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 4593.88,,CLAIM ADJUSTMENT 3, 2411.76,OTHER, 661.96, 4593.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43342,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 566.36,,CLAIM ADJUSTMENT 3, 283.55,OTHER, 69.77, 566.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43343,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 566.36,,CLAIM ADJUSTMENT 3, 298.98,OTHER, 83.02, 566.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43344,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 906.71,,CLAIM ADJUSTMENT 3, 482.77,OTHER, 136.45, 906.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43345,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 603.90,OTHER, 244.65, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43346,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 652.77,OTHER, 286.60, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43347,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 754.11,OTHER, 373.59, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43348,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 716.04,OTHER, 340.92, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43349,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 892.99,,CLAIM ADJUSTMENT 3, 701.64,OTHER, 328.55, 892.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43350,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1148.80,,CLAIM ADJUSTMENT 3, 2366.55,OTHER, 1148.80, 3726.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43351,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1384.25,,CLAIM ADJUSTMENT 3, 623.49,OTHER, 110.84, 1384.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43352,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 198.06,,CLAIM ADJUSTMENT 3, 256.43,OTHER, 159.42, 353.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43353,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1384.25,,CLAIM ADJUSTMENT 3, 637.38,OTHER, 122.76, 1384.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43354,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2350.90,,CLAIM ADJUSTMENT 3, 982.61,OTHER, 122.76, 2350.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43355,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2085.61,,CLAIM ADJUSTMENT 3, 1507.20,OTHER, 654.45, 2085.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43356,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 3410.78,,CLAIM ADJUSTMENT 3, 3143.54,OTHER, 1652.91, 3668.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43357,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 4593.88,,CLAIM ADJUSTMENT 3, 2486.35,OTHER, 725.99, 4593.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43358,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 4593.88,,CLAIM ADJUSTMENT 3, 2559.90,OTHER, 789.14, 4593.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43359,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43360,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 539.71,,CLAIM ADJUSTMENT 3, 1667.02,OTHER, 539.71, 2808.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43361,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 3135.31,,CLAIM ADJUSTMENT 3, 1786.42,OTHER, 572.31, 3135.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43362,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5153.51,,CLAIM ADJUSTMENT 3, 3662.54,OTHER, 1564.15, 5153.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43363,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1963.90,,CLAIM ADJUSTMENT 3, 889.66,OTHER, 161.63, 1963.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43364,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 191.60,,CLAIM ADJUSTMENT 3, 242.39,OTHER, 173.27, 394.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43365,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 191.60,,CLAIM ADJUSTMENT 3, 242.39,OTHER, 173.27, 394.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43366,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2085.61,,CLAIM ADJUSTMENT 3, 2146.09,OTHER, 1202.92, 2669.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43367,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 377.59,,CLAIM ADJUSTMENT 3, 199.77,OTHER, 96.75, 377.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43368,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 657.86,,CLAIM ADJUSTMENT 3, 266.50,OTHER, 96.75, 657.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43369,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1965.95,,CLAIM ADJUSTMENT 3, 2146.91,OTHER, 1478.34, 3369.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43370,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1965.95,,CLAIM ADJUSTMENT 3, 2146.91,OTHER, 1478.34, 3369.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43371,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43372,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43373,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43374,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 4781.78,,CLAIM ADJUSTMENT 3, 2579.17,OTHER, 748.07, 4781.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43375,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 146.68,,CLAIM ADJUSTMENT 3, 162.43,OTHER, 112.28, 255.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43376,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 146.68,,CLAIM ADJUSTMENT 3, 145.32,OTHER, 97.21, 221.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43377,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 191.60,,CLAIM ADJUSTMENT 3, 116.13,OTHER, 62.09, 191.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43378,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 76.24,OTHER, 51.17, 116.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43379,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 124.60,OTHER, 86.34, 208.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43380,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43381,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 62.55,OTHER, 36.98, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43382,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43383,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 99.80,OTHER, 58.91, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43384,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43385,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 161.46,OTHER, 113.20, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43386,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43387,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 62.55,OTHER, 36.98, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43388,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43389,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 171.96,OTHER, 122.45, 279.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43390,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43391,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 127.74,OTHER, 86.34, 215.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43392,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43393,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 189.58,OTHER, 137.97, 314.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43394,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43395,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 116.92,OTHER, 84.85, 193.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43396,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43397,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 299.54,OTHER, 138.19, 535.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43398,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43399,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 221.04,OTHER, 138.19, 377.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43400,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43401,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 177.44,OTHER, 127.28, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43402,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43403,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 71.21,OTHER, 44.60, 101.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43404,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43405,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 193.56,OTHER, 86.34, 347.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43406,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43407,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 223.50,OTHER, 86.34, 407.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43408,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1313.91,OTHER, 283.82, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43409,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1313.91,OTHER, 283.82, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43410,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43411,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43412,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1196.04,OTHER, 432.18, 2193.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43413,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1196.04,OTHER, 432.18, 2193.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43414,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43415,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43416,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1545.39,OTHER, 485.27, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43417,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1545.39,OTHER, 485.27, 2869.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43418,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43419,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43420,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.20,OTHER, 283.82, 1781.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43421,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43422,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 691.35,OTHER, 432.18, 1180.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43423,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43424,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 887.08,OTHER, 485.27, 1548.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43425,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43426,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 901.22,OTHER, 283.82, 1673.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43427,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 901.22,OTHER, 283.82, 1673.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43428,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43429,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43430,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1055.93,OTHER, 432.18, 1912.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43431,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1302.68,OTHER, 432.18, 2407.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43432,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43433,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43434,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 513.03,OTHER, 350.02, 797.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43435,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43436,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1290.59,OTHER, 283.82, 2454.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43437,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43438,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1374.81,OTHER, 432.18, 2552.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43439,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43440,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1265.96,OTHER, 485.27, 2308.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43441,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43442,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1076.14,OTHER, 495.38, 1923.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43443,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1076.14,OTHER, 495.38, 1923.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43444,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1076.14,OTHER, 495.38, 1923.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43445,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43446,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43447,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43448,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1270.81,OTHER, 495.38, 2313.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43449,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43450,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1681.52,OTHER, 779.04, 3002.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43451,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43452,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1224.87,OTHER, 508.57, 2215.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43453,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43454,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 1324.21,OTHER, 616.91, 2362.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43455,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 438.95,OTHER, 187.68, 616.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43456,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1532.99,OTHER, 779.04, 2704.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43457,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43458,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1233.59,OTHER, 508.57, 2232.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43459,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43460,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 1256.33,OTHER, 616.91, 2226.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43461,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 616.91,,CLAIM ADJUSTMENT 3, 438.95,OTHER, 187.68, 616.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43462,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1461.09,OTHER, 779.04, 2560.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43463,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43464,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1413.66,OTHER, 508.57, 2594.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43465,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43466,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2181.19,OTHER, 779.04, 4005.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43467,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2181.19,OTHER, 779.04, 4005.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43468,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43469,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43470,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43471,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43472,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43473,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43474,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43475,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43476,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43477,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43478,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43479,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43480,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43481,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 63.51,OTHER, 36.98, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43482,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43483,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43484,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 242.05,OTHER, 86.34, 444.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43485,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 243.52,OTHER, 86.34, 447.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43486,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43487,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43488,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 214.14,OTHER, 138.19, 363.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43489,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 240.03,OTHER, 138.19, 415.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43490,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43491,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43492,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 248.87,OTHER, 138.19, 433.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43493,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43494,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 165.10,OTHER, 86.34, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43495,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43496,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 62.55,OTHER, 36.98, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43497,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43498,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1211.40,OTHER, 283.82, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43499,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1211.40,OTHER, 283.82, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43500,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1211.40,OTHER, 283.82, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43501,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43502,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43503,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1356.87,OTHER, 432.18, 2737.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43504,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1356.87,OTHER, 432.18, 2737.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43505,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43506,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1817.25,OTHER, 485.27, 3415.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43507,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43508,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 1171.85,OTHER, 117.71, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43509,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 1171.85,OTHER, 117.71, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43510,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 1171.85,OTHER, 117.71, 2295.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43511,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 209.22,OTHER, 117.71, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43512,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 209.22,OTHER, 117.71, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43513,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 117.71,,CLAIM ADJUSTMENT 3, 209.22,OTHER, 117.71, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43514,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43515,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43516,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43517,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43518,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1915.21,OTHER, 495.38, 4880.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43519,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43520,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43521,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43522,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43523,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43524,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43525,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43526,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43527,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.01,OTHER, 86.34, 297.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43528,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.01,OTHER, 86.34, 297.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43529,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43530,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43531,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 247.65,OTHER, 138.19, 430.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43532,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43533,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 350.60,OTHER, 138.19, 637.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43534,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43535,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 382.63,OTHER, 138.19, 701.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43536,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43537,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 293.50,OTHER, 138.19, 522.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43538,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43539,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 265.86,OTHER, 138.19, 467.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43540,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43541,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 161.46,OTHER, 113.20, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43542,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43543,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 142.64,OTHER, 86.34, 245.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43544,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43545,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 63.06,OTHER, 36.98, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43546,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 163.44,OTHER, 113.20, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43547,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 96.05,OTHER, 37.54, 146.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43548,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 259.24,OTHER, 138.19, 454.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43549,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43550,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 166.91,OTHER, 118.00, 268.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43551,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43552,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 407.08,OTHER, 138.19, 750.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43553,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43554,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1459.38,OTHER, 283.82, 2793.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43555,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1459.38,OTHER, 283.82, 2793.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43556,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1459.38,OTHER, 283.82, 2793.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43557,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43558,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43559,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43560,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 664.89,OTHER, 483.75, 1102.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43561,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43562,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1649.11,OTHER, 283.82, 3173.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43563,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1649.11,OTHER, 283.82, 3173.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43564,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43565,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43566,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1665.51,OTHER, 432.18, 3136.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43567,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43568,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1439.18,OTHER, 283.82, 2752.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43569,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43570,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1652.58,OTHER, 432.18, 3110.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43571,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43572,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1580.48,OTHER, 485.27, 2940.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43573,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43574,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1712.29,OTHER, 508.57, 3193.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43575,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43576,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1894.78,OTHER, 508.57, 3559.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43577,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43578,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1677.93,OTHER, 508.57, 3124.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43579,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43580,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2119.80,OTHER, 779.04, 3881.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43581,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43582,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2539.54,OTHER, 779.04, 4724.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43583,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43584,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2390.20,OTHER, 779.04, 4424.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43585,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43586,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43587,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43588,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43589,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 236.81,OTHER, 138.19, 409.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43590,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43591,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 193.87,OTHER, 138.19, 323.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43592,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43593,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1261.16,OTHER, 283.82, 2395.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43594,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1261.16,OTHER, 283.82, 2395.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43595,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43596,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43597,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1256.10,OTHER, 432.18, 2314.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43598,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43599,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 894.65,OTHER, 485.27, 1563.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43600,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43601,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1751.53,OTHER, 508.57, 3272.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43602,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43603,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2629.35,OTHER, 779.04, 4904.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43604,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43605,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43606,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43607,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43608,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43609,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43610,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43611,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 164.19,OTHER, 86.34, 288.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43612,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43613,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 224.35,OTHER, 86.34, 408.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43614,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43615,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 208.71,OTHER, 86.34, 377.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43616,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 208.71,OTHER, 86.34, 377.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43617,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 215.71,OTHER, 86.34, 391.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43618,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43619,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43620,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43621,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 149.11,OTHER, 86.34, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43622,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 149.11,OTHER, 86.34, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43623,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 149.11,OTHER, 86.34, 257.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43624,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43625,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43626,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43627,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 175.84,OTHER, 86.34, 311.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43628,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.06,OTHER, 86.34, 298.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43629,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.06,OTHER, 86.34, 298.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43630,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43631,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43632,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43633,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 235.06,OTHER, 138.19, 405.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43634,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 235.06,OTHER, 138.19, 405.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43635,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 240.36,OTHER, 138.19, 416.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43636,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43637,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43638,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43639,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 219.70,OTHER, 86.34, 399.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43640,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 214.45,OTHER, 86.34, 389.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43641,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 214.45,OTHER, 86.34, 389.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43642,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43643,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43644,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43645,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 206.56,OTHER, 86.34, 373.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43646,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 211.81,OTHER, 86.34, 383.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43647,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 206.56,OTHER, 86.34, 373.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43648,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43649,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43650,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43651,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 230.04,OTHER, 86.34, 420.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43652,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 223.50,OTHER, 86.34, 407.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43653,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43654,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43655,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43656,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 230.83,OTHER, 86.34, 421.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43657,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 230.83,OTHER, 86.34, 421.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43658,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 237.37,OTHER, 86.34, 435.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43659,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43660,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43661,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43662,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 99.80,OTHER, 58.91, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43663,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 125.68,OTHER, 81.70, 186.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43664,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 99.80,OTHER, 58.91, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43665,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43666,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43667,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43668,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 213.73,OTHER, 86.34, 387.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43669,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 207.73,OTHER, 86.34, 375.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43670,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 207.74,OTHER, 86.34, 375.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43671,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43672,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43673,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43674,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 238.18,OTHER, 86.34, 436.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43675,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 243.44,OTHER, 86.34, 447.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43676,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 238.18,OTHER, 86.34, 436.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43677,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43678,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43679,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43680,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 238.48,OTHER, 138.19, 412.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43681,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 231.94,OTHER, 138.19, 399.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43682,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 231.94,OTHER, 138.19, 399.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43683,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43684,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43685,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43686,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 220.36,OTHER, 86.34, 400.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43687,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 220.42,OTHER, 86.34, 401.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43688,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 225.67,OTHER, 86.34, 411.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43689,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43690,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43691,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43692,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43693,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 174.69,OTHER, 86.34, 309.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43694,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43695,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43696,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43697,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43698,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43699,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43700,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43701,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43702,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43703,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 169.45,OTHER, 86.34, 298.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43704,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.96,OTHER, 86.34, 334.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43705,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43706,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43707,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43708,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43709,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43710,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43711,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43712,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43713,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43714,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43715,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43716,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43717,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43718,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43719,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1061.06,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43720,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43721,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43722,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43723,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43724,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43725,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43726,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43727,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43728,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43729,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43730,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 860.58,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43731,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43732,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 955.84,OTHER, 283.82, 1993.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43733,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43734,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43735,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43736,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43737,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43738,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43739,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43740,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43741,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43742,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43743,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43744,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43745,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43746,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43747,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1484.34,OTHER, 432.18, 2772.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43748,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1484.34,OTHER, 432.18, 2772.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43749,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43750,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43751,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43752,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43753,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43754,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43755,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43756,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1055.55,OTHER, 508.57, 1875.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43757,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43758,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1797.05,OTHER, 779.04, 3234.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43759,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1797.05,OTHER, 779.04, 3234.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43760,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1797.05,OTHER, 779.04, 3234.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43761,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43762,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43763,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43764,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43765,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43766,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43767,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43768,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43769,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43770,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43771,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43772,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43773,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43774,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43775,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43776,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43777,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43778,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43779,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1764.11,OTHER, 508.57, 3297.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43780,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43781,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43782,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43783,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43784,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43785,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43786,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43787,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43788,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43789,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43790,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43791,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43792,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43793,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43794,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 394.54,OTHER, 143.52, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43795,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43796,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1450.34,OTHER, 779.04, 2538.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43797,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1450.34,OTHER, 779.04, 2538.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43798,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43799,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43800,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43801,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43802,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43803,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 43804,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 196.99,OTHER, 88.46, 353.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43805,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 196.99,OTHER, 88.46, 353.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43806,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 196.99,OTHER, 88.46, 353.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43807,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43808,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43809,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43810,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43811,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43812,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43813,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43814,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 190.98,OTHER, 88.46, 341.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43815,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43816,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43817,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43818,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43819,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 234.40,OTHER, 146.51, 446.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43820,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 234.40,OTHER, 146.51, 446.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43821,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 96.05,OTHER, 37.54, 146.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43822,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 146.51,,CLAIM ADJUSTMENT 3, 96.05,OTHER, 37.54, 146.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43823,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 202.98,OTHER, 88.46, 365.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43824,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 202.98,OTHER, 88.46, 365.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43825,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 208.23,OTHER, 88.46, 375.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43826,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43827,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43828,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 88.46,,CLAIM ADJUSTMENT 3, 75.32,OTHER, 37.54, 88.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43829,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 210.73,OTHER, 86.34, 381.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43830,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 204.73,OTHER, 86.34, 369.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43831,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 204.73,OTHER, 86.34, 369.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43832,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43833,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43834,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43835,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 269.16,OTHER, 138.19, 474.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43836,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 274.41,OTHER, 138.19, 484.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43837,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 269.16,OTHER, 138.19, 474.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43838,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43839,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43840,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43841,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 402.07,OTHER, 138.19, 740.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43842,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 395.36,OTHER, 138.19, 727.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43843,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 395.36,OTHER, 138.19, 727.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43844,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43845,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43846,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43847,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 153.37,OTHER, 86.34, 266.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43848,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43849,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 243.07,OTHER, 86.34, 446.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43850,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 237.82,OTHER, 86.34, 436.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43851,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 237.82,OTHER, 86.34, 436.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43852,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43853,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43854,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43855,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 74.90,OTHER, 36.98, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43856,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 74.90,OTHER, 36.98, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43857,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 116.89,OTHER, 73.96, 168.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43858,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43859,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43860,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43861,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 218.95,OTHER, 138.19, 373.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43862,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 218.95,OTHER, 138.19, 373.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43863,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 225.30,OTHER, 138.19, 386.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43864,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43865,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43866,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43867,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 243.37,OTHER, 138.19, 422.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43868,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 236.76,OTHER, 138.19, 409.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43869,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 236.76,OTHER, 138.19, 409.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43870,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43871,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43872,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43873,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 186.56,OTHER, 86.34, 333.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43874,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 186.56,OTHER, 86.34, 333.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43875,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43876,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43877,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 250.19,OTHER, 86.34, 460.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43878,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 244.84,OTHER, 86.34, 450.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43879,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 244.94,OTHER, 86.34, 450.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43880,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43881,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43882,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43883,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 134.33,OTHER, 86.34, 228.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43884,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 134.33,OTHER, 86.34, 228.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43885,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 134.33,OTHER, 86.34, 228.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43886,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43887,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43888,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43889,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43890,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43891,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43892,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43893,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43894,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43895,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43896,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43897,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 179.26,OTHER, 86.34, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43898,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43899,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 172.49,OTHER, 86.34, 304.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43900,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43901,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43902,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43903,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43904,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43905,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43906,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43907,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43908,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43909,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43910,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 86.34,,CLAIM ADJUSTMENT 3, 74.56,OTHER, 37.54, 86.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43911,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43912,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43913,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43914,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1193.14,OTHER, 283.82, 2258.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43915,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43916,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43917,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43918,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43919,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43920,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43921,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43922,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43923,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43924,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1186.77,OTHER, 283.82, 2246.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43925,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43926,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43927,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43928,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43929,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43930,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43931,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43932,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43933,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43934,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43935,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43936,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43937,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43938,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43939,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1435.02,OTHER, 432.18, 2673.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43940,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1428.39,OTHER, 432.18, 2660.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43941,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1428.39,OTHER, 432.18, 2660.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43942,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43943,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43944,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43945,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43946,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43947,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 774.28,OTHER, 485.27, 1322.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43948,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43949,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43950,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43951,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 796.22,OTHER, 495.38, 1361.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43952,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 796.22,OTHER, 495.38, 1361.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43953,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43954,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43955,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43956,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43957,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43958,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43959,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43960,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1565.98,OTHER, 508.57, 2899.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43961,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43962,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43963,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43964,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43965,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43966,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43967,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1953.37,OTHER, 779.04, 3547.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43968,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1953.37,OTHER, 779.04, 3547.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43969,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43970,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43971,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43972,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43973,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43974,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43975,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43976,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43977,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43978,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43979,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43980,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1661.10,OTHER, 508.57, 3090.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43981,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43982,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43983,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43984,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43985,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43986,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43987,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43988,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43989,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43990,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43991,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43992,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43993,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43994,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43995,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 2433.15,OTHER, 779.04, 4510.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43996,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43997,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43998,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 43999,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44000,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44001,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44002,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44003,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44004,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44005,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44006,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44007,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44008,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44009,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44010,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44011,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 102.58,OTHER, 71.38, 162.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44012,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 102.58,OTHER, 71.38, 162.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44013,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44014,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.37,,CLAIM ADJUSTMENT 3, 76.00,OTHER, 37.54, 90.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44015,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 172.76,,CLAIM ADJUSTMENT 3, 83.13,OTHER, 36.98, 172.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44016,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 172.76,,CLAIM ADJUSTMENT 3, 105.42,OTHER, 37.54, 172.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44017,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 322.43,OTHER, 138.19, 581.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44018,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 322.43,OTHER, 138.19, 581.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44019,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44020,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 93.08,OTHER, 37.54, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44021,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 1346.03,OTHER, 283.82, 2565.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44022,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.82,,CLAIM ADJUSTMENT 3, 268.54,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44023,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 1544.22,OTHER, 432.18, 2892.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44024,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 432.18,,CLAIM ADJUSTMENT 3, 321.53,OTHER, 143.52, 432.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44025,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 1743.20,OTHER, 485.27, 3266.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44026,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 485.27,,CLAIM ADJUSTMENT 3, 340.49,OTHER, 143.52, 485.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44027,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 813.20,,CLAIM ADJUSTMENT 3, 3113.75,OTHER, 813.20, 5860.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44028,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 813.20,,CLAIM ADJUSTMENT 3, 473.04,OTHER, 156.77, 813.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44029,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1743.46,OTHER, 495.38, 3262.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44030,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44031,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 2609.45,OTHER, 276.02, 5105.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44032,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 2609.45,OTHER, 276.02, 5105.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44033,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 265.76,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44034,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 276.02,,CLAIM ADJUSTMENT 3, 265.76,OTHER, 143.52, 318.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44035,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 3021.78,OTHER, 426.91, 5860.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44036,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 3021.78,OTHER, 426.91, 5860.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44037,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 319.65,OTHER, 143.52, 426.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44038,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 426.91,,CLAIM ADJUSTMENT 3, 319.65,OTHER, 143.52, 426.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44039,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 3385.13,OTHER, 475.94, 6566.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44040,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 3385.13,OTHER, 475.94, 6566.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44041,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 3385.13,OTHER, 475.94, 6566.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44042,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 337.16,OTHER, 143.52, 475.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44043,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 337.16,OTHER, 143.52, 475.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44044,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 475.94,,CLAIM ADJUSTMENT 3, 337.16,OTHER, 143.52, 475.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44045,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1689.68,OTHER, 508.57, 3148.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44046,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1689.68,OTHER, 508.57, 3148.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44047,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44048,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 400.25,OTHER, 187.68, 508.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44049,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1837.06,OTHER, 779.04, 3314.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44050,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 496.85,OTHER, 187.68, 779.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44051,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44052,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44053,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44054,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44055,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44056,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 371.17,OTHER, 127.36, 684.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44057,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 371.17,OTHER, 127.36, 684.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44058,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 371.17,OTHER, 127.36, 684.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44059,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 89.21,OTHER, 37.54, 127.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44060,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 127.36,,CLAIM ADJUSTMENT 3, 89.21,OTHER, 37.54, 127.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44061,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44062,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44063,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 248.14,OTHER, 166.15, 378.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44064,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 230.64,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44065,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 429.88,OTHER, 249.71, 743.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44066,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 249.71,,CLAIM ADJUSTMENT 3, 132.91,OTHER, 37.54, 249.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44067,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1495.57,OTHER, 495.38, 2764.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44068,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 1495.57,OTHER, 495.38, 2764.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44069,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44070,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 495.38,,CLAIM ADJUSTMENT 3, 344.10,OTHER, 143.52, 495.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44071,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44072,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44073,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 385.53,OTHER, 141.55, 706.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44074,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 385.53,OTHER, 141.55, 706.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44075,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 385.53,OTHER, 141.55, 706.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44076,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44077,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44078,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44079,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 286.59,OTHER, 90.89, 531.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44080,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44081,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 281.44,OTHER, 133.37, 501.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44082,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 281.44,OTHER, 133.37, 501.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44083,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 281.44,OTHER, 133.37, 501.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44084,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 288.12,OTHER, 133.37, 514.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44085,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44086,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44087,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44088,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44089,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 503.49,OTHER, 141.55, 942.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44090,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44091,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44092,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44093,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44094,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44095,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 462.74,OTHER, 141.55, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44096,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44097,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44098,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44099,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44100,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44101,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 163.97,,CLAIM ADJUSTMENT 3, 468.07,OTHER, 163.97, 861.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44102,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 163.97,,CLAIM ADJUSTMENT 3, 200.02,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44103,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44104,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44105,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44106,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44107,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.41,OTHER, 141.55, 776.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44108,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44109,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44110,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44111,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44112,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44113,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 414.50,OTHER, 141.55, 764.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44114,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44115,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 214.87,OTHER, 133.37, 367.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44116,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 163.37,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44117,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 408.73,OTHER, 141.55, 752.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44118,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44119,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 507.55,OTHER, 141.55, 950.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44120,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44121,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 775.60,OTHER, 90.89, 1513.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44122,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44123,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 290.56,OTHER, 133.37, 519.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44124,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44125,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 419.77,OTHER, 141.55, 774.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44126,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44127,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 471.58,OTHER, 141.55, 878.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44128,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 471.58,OTHER, 141.55, 878.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44129,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 471.58,OTHER, 141.55, 878.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44130,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44131,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44132,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44133,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 322.12,OTHER, 90.89, 613.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44134,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 322.12,OTHER, 90.89, 613.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44135,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44136,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 90.89,,CLAIM ADJUSTMENT 3, 173.92,OTHER, 90.89, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44137,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 408.48,OTHER, 141.55, 752.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44138,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44139,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 813.95,OTHER, 137.10, 1568.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44140,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 526.64,OTHER, 137.10, 991.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44141,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 526.64,OTHER, 137.10, 991.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44142,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 190.42,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44143,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 190.42,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44144,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 137.10,,CLAIM ADJUSTMENT 3, 190.42,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44145,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44146,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 300.33,OTHER, 133.37, 539.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44147,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44148,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44149,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44150,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44151,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44152,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44153,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 133.37, 351.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44154,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44155,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44156,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44157,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44158,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44159,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44160,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44161,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44162,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.37,,CLAIM ADJUSTMENT 3, 189.09,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44163,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44164,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44165,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44166,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44167,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44168,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44169,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44170,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44171,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44172,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44173,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44174,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44175,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 34.54,,CLAIM ADJUSTMENT 3, 78.82,OTHER, 21.15, 181.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44176,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44177,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44178,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44179,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 185.61,OTHER, 125.13, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44180,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44181,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44182,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44183,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 182.74,,CLAIM ADJUSTMENT 3, 181.00,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44184,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 281.03,OTHER, 175.87, 480.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44185,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 281.03,OTHER, 175.87, 480.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44186,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 281.03,OTHER, 175.87, 480.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44187,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 198.15,OTHER, 99.36, 230.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44188,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 230.75,,CLAIM ADJUSTMENT 3, 198.15,OTHER, 99.36, 230.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44189,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44190,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44191,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44192,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 171.54,OTHER, 81.44, 285.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44193,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 235.21,OTHER, 81.44, 588.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44194,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 235.21,OTHER, 81.44, 588.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44195,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 235.21,OTHER, 81.44, 588.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44196,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44197,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44198,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44199,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44200,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44201,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44202,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 185.68,,CLAIM ADJUSTMENT 3, 182.05,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44203,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 116.40,OTHER, 73.53, 167.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44204,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 70.96,OTHER, 18.55, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44205,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 232.03,,CLAIM ADJUSTMENT 3, 414.07,OTHER, 232.03, 720.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44206,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 158.67,OTHER, 84.28, 343.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44207,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 158.67,OTHER, 84.28, 343.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44208,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 59.28,OTHER, 18.55, 105.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44209,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 105.49,,CLAIM ADJUSTMENT 3, 59.28,OTHER, 18.55, 105.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44210,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 42.36,,CLAIM ADJUSTMENT 3, 154.63,OTHER, 42.36, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44211,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 204.30,OTHER, 138.19, 343.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44212,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.19,,CLAIM ADJUSTMENT 3, 70.96,OTHER, 18.55, 138.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44213,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 660.83,OTHER, 156.82, 1251.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44214,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 660.83,OTHER, 156.82, 1251.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44215,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 171.75,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44216,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 156.82,,CLAIM ADJUSTMENT 3, 171.75,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44217,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 533.81,OTHER, 206.35, 972.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44218,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 533.81,OTHER, 206.35, 972.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44219,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 189.44,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44220,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 206.35,,CLAIM ADJUSTMENT 3, 189.44,OTHER, 99.36, 220.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44221,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 320.35,,CLAIM ADJUSTMENT 3, 757.92,OTHER, 320.35, 1367.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44222,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 320.35,,CLAIM ADJUSTMENT 3, 230.15,OTHER, 99.36, 320.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44223,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 322.62,,CLAIM ADJUSTMENT 3, 899.81,OTHER, 322.62, 1651.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44224,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 322.62,,CLAIM ADJUSTMENT 3, 230.96,OTHER, 99.36, 322.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44225,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 548.80,,CLAIM ADJUSTMENT 3, 1092.65,OTHER, 548.80, 1930.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44226,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 548.80,,CLAIM ADJUSTMENT 3, 311.74,OTHER, 99.36, 548.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44227,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 864.03,OTHER, 423.08, 1531.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44228,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 266.84,OTHER, 99.36, 423.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44229,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 344.89,OTHER, 215.00, 490.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44230,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 423.08,,CLAIM ADJUSTMENT 3, 266.84,OTHER, 99.36, 423.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44231,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 830.31,OTHER, 410.92, 1470.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44232,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 262.50,OTHER, 99.36, 410.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44233,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 1103.77,OTHER, 410.92, 2018.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44234,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 410.92,,CLAIM ADJUSTMENT 3, 262.50,OTHER, 99.36, 410.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44235,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 1111.16,OTHER, 359.95, 2058.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44236,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 244.29,OTHER, 99.36, 359.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44237,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 624.07,OTHER, 359.95, 1080.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44238,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 359.95,,CLAIM ADJUSTMENT 3, 244.29,OTHER, 99.36, 359.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44239,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 672.34,OTHER, 360.01, 1177.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44240,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44241,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 559.38,OTHER, 360.01, 950.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44242,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44243,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 1228.06,OTHER, 360.01, 2292.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44244,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44245,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 1294.05,OTHER, 360.01, 2425.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44246,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 360.01,,CLAIM ADJUSTMENT 3, 244.32,OTHER, 99.36, 360.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44247,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44248,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44249,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 1149.19,OTHER, 775.51, 1767.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44250,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 1149.19,OTHER, 775.51, 1767.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44251,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 518.51,OTHER, 99.36, 1127.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44252,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 518.51,OTHER, 99.36, 1127.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44253,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 2267.81,OTHER, 1127.76, 4012.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44254,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1127.76,,CLAIM ADJUSTMENT 3, 518.51,OTHER, 99.36, 1127.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44255,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 815.01,OTHER, 444.92, 1423.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44256,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 815.01,OTHER, 444.92, 1423.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44257,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 274.64,OTHER, 99.36, 444.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44258,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 444.92,,CLAIM ADJUSTMENT 3, 274.64,OTHER, 99.36, 444.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44259,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.54,,CLAIM ADJUSTMENT 3, 635.79,OTHER, 283.54, 1140.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44260,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 283.54,,CLAIM ADJUSTMENT 3, 217.00,OTHER, 99.36, 283.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44261,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 300.36,,CLAIM ADJUSTMENT 3, 984.09,OTHER, 300.36, 1831.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44262,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 300.36,,CLAIM ADJUSTMENT 3, 223.01,OTHER, 99.36, 300.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44263,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 443.12,,CLAIM ADJUSTMENT 3, 1050.06,OTHER, 443.12, 1895.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44264,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 443.12,,CLAIM ADJUSTMENT 3, 274.00,OTHER, 99.36, 443.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44265,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 742.64,,CLAIM ADJUSTMENT 3, 684.67,OTHER, 447.20, 1019.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44266,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 742.64,,CLAIM ADJUSTMENT 3, 380.97,OTHER, 99.36, 742.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44267,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 2685.69,OTHER, 1509.32, 4668.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44268,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 744.80,OTHER, 176.64, 1509.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44269,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 2768.70,OTHER, 1509.32, 4835.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44270,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1509.32,,CLAIM ADJUSTMENT 3, 744.80,OTHER, 176.64, 1509.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44271,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.78,,CLAIM ADJUSTMENT 3, 34.30,OTHER, 19.78, 59.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44272,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.18,,CLAIM ADJUSTMENT 3, 32.49,OTHER, 12.18, 59.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44273,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44274,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 10.09,,CLAIM ADJUSTMENT 3, 70.69,OTHER, 10.09, 137.05,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44275,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 15.20,,CLAIM ADJUSTMENT 3, 122.16,OTHER, 15.20, 237.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44276,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.28,,CLAIM ADJUSTMENT 3, 97.60,OTHER, 19.28, 186.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44277,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.28,,CLAIM ADJUSTMENT 3, 97.60,OTHER, 19.28, 186.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44278,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.50,,CLAIM ADJUSTMENT 3, 83.55,OTHER, 12.50, 161.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44279,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.50,,CLAIM ADJUSTMENT 3, 83.55,OTHER, 12.50, 161.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44280,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 68.59,,CLAIM ADJUSTMENT 3, 155.85,OTHER, 68.59, 280.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44281,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.76,,CLAIM ADJUSTMENT 3, 78.98,OTHER, 11.76, 152.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44282,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 22.37,,CLAIM ADJUSTMENT 3, 69.30,OTHER, 22.37, 128.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44283,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 46.28,,CLAIM ADJUSTMENT 3, 229.30,OTHER, 46.28, 438.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44284,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 88.95,OTHER, 20.98, 172.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44285,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 88.95,OTHER, 20.98, 172.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44286,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.13,,CLAIM ADJUSTMENT 3, 53.39,OTHER, 19.13, 98.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44287,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.13,,CLAIM ADJUSTMENT 3, 53.39,OTHER, 19.13, 98.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44288,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.50,,CLAIM ADJUSTMENT 3, 80.17,OTHER, 19.50, 151.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44289,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 31.20,,CLAIM ADJUSTMENT 3, 54.61,OTHER, 31.20, 94.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44290,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 80.03,OTHER, 19.08, 151.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44291,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 79.17,OTHER, 19.08, 149.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44292,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.52,,CLAIM ADJUSTMENT 3, 63.95,OTHER, 9.52, 123.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44293,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 22.37,,CLAIM ADJUSTMENT 3, 28.28,OTHER, 20.21, 46.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44294,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 83.69,OTHER, 19.08, 158.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44295,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 22.03,,CLAIM ADJUSTMENT 3, 53.47,OTHER, 22.03, 96.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44296,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 79.81,OTHER, 19.08, 151.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44297,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.78,,CLAIM ADJUSTMENT 3, 44.64,OTHER, 19.78, 80.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44298,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.78,,CLAIM ADJUSTMENT 3, 145.91,OTHER, 19.78, 283.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44299,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.36,,CLAIM ADJUSTMENT 3, 64.76,OTHER, 20.36, 120.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44300,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.16,,CLAIM ADJUSTMENT 3, 121.34,OTHER, 17.16, 235.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44301,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.50,,CLAIM ADJUSTMENT 3, 84.76,OTHER, 19.50, 160.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44302,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 32.53,,CLAIM ADJUSTMENT 3, 134.69,OTHER, 32.53, 254.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44303,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 26.84,,CLAIM ADJUSTMENT 3, 90.91,OTHER, 26.84, 169.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44304,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 56.90,OTHER, 10.75, 186.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44305,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 56.90,OTHER, 10.75, 186.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44306,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 23.85,OTHER, 17.20, 39.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44307,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.14,,CLAIM ADJUSTMENT 3, 23.85,OTHER, 17.20, 39.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44308,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44309,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44310,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44311,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44312,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44313,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44314,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44315,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44316,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44317,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44318,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44319,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44320,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44321,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44322,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44323,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44324,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44325,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44326,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44327,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 4.56,,CLAIM ADJUSTMENT 3, 34.88,OTHER, 4.56, 67.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44328,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 4.56,,CLAIM ADJUSTMENT 3, 34.88,OTHER, 4.56, 67.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44329,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 4.56,,CLAIM ADJUSTMENT 3, 34.88,OTHER, 4.56, 67.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44330,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 20.93,OTHER, 3.24, 40.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44331,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 20.93,OTHER, 3.24, 40.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44332,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 20.93,OTHER, 3.24, 40.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44333,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 3.24,,CLAIM ADJUSTMENT 3, 7.12,OTHER, 3.24, 12.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44334,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 3.12,,CLAIM ADJUSTMENT 3, 8.07,OTHER, 3.12, 14.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44335,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 33.86,OTHER, 12.40, 62.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44336,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 33.86,OTHER, 12.40, 62.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44337,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 75.71,OTHER, 12.40, 146.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44338,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.40,,CLAIM ADJUSTMENT 3, 75.71,OTHER, 12.40, 146.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44339,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 105.66,,CLAIM ADJUSTMENT 3, 145.60,OTHER, 105.66, 241.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44340,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 105.66,,CLAIM ADJUSTMENT 3, 145.60,OTHER, 105.66, 241.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44341,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 94.12,,CLAIM ADJUSTMENT 3, 262.66,OTHER, 94.12, 482.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44342,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 131.99,,CLAIM ADJUSTMENT 3, 428.98,OTHER, 131.99, 797.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44343,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44344,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44345,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44346,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.50,,CLAIM ADJUSTMENT 3, 53.15,OTHER, 6.50, 103.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44347,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.76,,CLAIM ADJUSTMENT 3, 38.90,OTHER, 11.76, 72.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44348,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 55.61,,CLAIM ADJUSTMENT 3, 146.83,OTHER, 55.61, 268.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44349,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.13,,CLAIM ADJUSTMENT 3, 20.13,OTHER, 7.13, 37.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44350,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.13,,CLAIM ADJUSTMENT 3, 20.13,OTHER, 7.13, 37.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44351,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.21,,CLAIM ADJUSTMENT 3, 28.92,OTHER, 11.21, 52.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44352,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.21,,CLAIM ADJUSTMENT 3, 28.92,OTHER, 11.21, 52.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44353,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 8.33,,CLAIM ADJUSTMENT 3, 60.58,OTHER, 8.33, 117.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44354,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 8.33,,CLAIM ADJUSTMENT 3, 60.58,OTHER, 8.33, 117.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44355,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 50.88,OTHER, 13.98, 95.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44356,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.36,,CLAIM ADJUSTMENT 3, 71.06,OTHER, 19.36, 133.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44357,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.82,,CLAIM ADJUSTMENT 3, 109.86,OTHER, 20.82, 210.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44358,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.14,,CLAIM ADJUSTMENT 3, 80.16,OTHER, 24.14, 149.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44359,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.14,,CLAIM ADJUSTMENT 3, 80.16,OTHER, 24.14, 149.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44360,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 63.10,OTHER, 20.98, 116.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44361,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.98,,CLAIM ADJUSTMENT 3, 63.10,OTHER, 20.98, 116.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44362,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.34,,CLAIM ADJUSTMENT 3, 50.79,OTHER, 9.34, 97.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44363,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.34,,CLAIM ADJUSTMENT 3, 50.79,OTHER, 9.34, 97.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44364,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 42.16,,CLAIM ADJUSTMENT 3, 100.38,OTHER, 42.16, 181.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44365,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 46.34,,CLAIM ADJUSTMENT 3, 121.92,OTHER, 46.34, 222.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44366,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 30.37,,CLAIM ADJUSTMENT 3, 50.20,OTHER, 30.37, 86.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44367,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 27.31,,CLAIM ADJUSTMENT 3, 116.31,OTHER, 27.31, 220.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44368,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 14.24,,CLAIM ADJUSTMENT 3, 49.78,OTHER, 14.24, 93.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44369,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 23.30,,CLAIM ADJUSTMENT 3, 63.44,OTHER, 23.30, 116.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44370,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.22,,CLAIM ADJUSTMENT 3, 36.36,OTHER, 7.22, 69.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44371,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.22,,CLAIM ADJUSTMENT 3, 36.36,OTHER, 7.22, 69.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44372,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.22,,CLAIM ADJUSTMENT 3, 33.07,OTHER, 7.22, 62.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44373,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.31,,CLAIM ADJUSTMENT 3, 19.33,OTHER, 6.31, 35.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44374,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.38,,CLAIM ADJUSTMENT 3, 33.34,OTHER, 6.38, 63.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44375,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 22.92,,CLAIM ADJUSTMENT 3, 56.73,OTHER, 22.92, 102.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44376,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 42.62,,CLAIM ADJUSTMENT 3, 126.67,OTHER, 42.62, 244.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44377,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 42.62,,CLAIM ADJUSTMENT 3, 126.67,OTHER, 42.62, 244.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44378,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 42.62,,CLAIM ADJUSTMENT 3, 126.67,OTHER, 42.62, 244.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44379,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 38.58,,CLAIM ADJUSTMENT 3, 123.66,OTHER, 38.58, 229.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44380,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.43,,CLAIM ADJUSTMENT 3, 34.08,OTHER, 7.43, 64.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44381,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.43,,CLAIM ADJUSTMENT 3, 34.08,OTHER, 7.43, 64.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44382,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.43,,CLAIM ADJUSTMENT 3, 34.08,OTHER, 7.43, 64.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44383,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.70,,CLAIM ADJUSTMENT 3, 69.24,OTHER, 19.70, 129.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44384,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 8.69,,CLAIM ADJUSTMENT 3, 49.97,OTHER, 8.69, 96.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44385,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.58,,CLAIM ADJUSTMENT 3, 44.47,OTHER, 18.58, 80.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44386,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.74,,CLAIM ADJUSTMENT 3, 65.14,OTHER, 17.74, 122.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44387,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 27.30,,CLAIM ADJUSTMENT 3, 87.25,OTHER, 27.30, 162.05,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44388,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 27.30,,CLAIM ADJUSTMENT 3, 87.25,OTHER, 27.30, 162.05,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44389,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.29,,CLAIM ADJUSTMENT 3, 59.01,OTHER, 24.29, 106.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44390,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 36.36,,CLAIM ADJUSTMENT 3, 127.93,OTHER, 36.36, 240.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44391,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 36.36,,CLAIM ADJUSTMENT 3, 127.93,OTHER, 36.36, 240.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44392,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 56.46,OTHER, 15.47, 105.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44393,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 8.28,,CLAIM ADJUSTMENT 3, 13.69,OTHER, 8.28, 23.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44394,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.87,,CLAIM ADJUSTMENT 3, 73.71,OTHER, 17.87, 139.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44395,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.06,,CLAIM ADJUSTMENT 3, 87.73,OTHER, 24.06, 164.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44396,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.06,,CLAIM ADJUSTMENT 3, 87.73,OTHER, 24.06, 164.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44397,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 23.47,,CLAIM ADJUSTMENT 3, 66.31,OTHER, 23.47, 121.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44398,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 23.47,,CLAIM ADJUSTMENT 3, 66.31,OTHER, 23.47, 121.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44399,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 34.69,,CLAIM ADJUSTMENT 3, 190.19,OTHER, 34.69, 365.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44400,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 34.69,,CLAIM ADJUSTMENT 3, 214.01,OTHER, 34.69, 412.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44401,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.37,,CLAIM ADJUSTMENT 3, 47.49,OTHER, 9.37, 90.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44402,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.37,,CLAIM ADJUSTMENT 3, 47.49,OTHER, 9.37, 90.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44403,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.28,,CLAIM ADJUSTMENT 3, 41.70,OTHER, 19.28, 74.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44404,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.63,,CLAIM ADJUSTMENT 3, 59.73,OTHER, 16.63, 111.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44405,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.37,,CLAIM ADJUSTMENT 3, 31.62,OTHER, 7.37, 59.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44406,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.37,,CLAIM ADJUSTMENT 3, 31.62,OTHER, 7.37, 59.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44407,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.37,,CLAIM ADJUSTMENT 3, 31.62,OTHER, 7.37, 59.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44408,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 39.11,OTHER, 7.46, 74.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44409,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 39.11,OTHER, 7.46, 74.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44410,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.62,,CLAIM ADJUSTMENT 3, 93.47,OTHER, 13.62, 181.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44411,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.62,,CLAIM ADJUSTMENT 3, 93.47,OTHER, 13.62, 181.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44412,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.97,,CLAIM ADJUSTMENT 3, 45.06,OTHER, 16.97, 82.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44413,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 76.21,OTHER, 9.31, 148.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44414,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 21.72,,CLAIM ADJUSTMENT 3, 72.23,OTHER, 21.72, 134.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44415,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 21.72,,CLAIM ADJUSTMENT 3, 72.23,OTHER, 21.72, 134.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44416,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 75.36,OTHER, 26.66, 138.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44417,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 75.36,OTHER, 26.66, 138.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44418,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 36.38,,CLAIM ADJUSTMENT 3, 127.42,OTHER, 36.38, 238.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44419,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 36.38,,CLAIM ADJUSTMENT 3, 127.42,OTHER, 36.38, 238.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44420,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 27.06,,CLAIM ADJUSTMENT 3, 93.87,OTHER, 27.06, 175.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44421,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 40.24,,CLAIM ADJUSTMENT 3, 135.49,OTHER, 40.24, 252.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44422,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 40.24,,CLAIM ADJUSTMENT 3, 135.49,OTHER, 40.24, 252.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44423,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 46.51,,CLAIM ADJUSTMENT 3, 83.83,OTHER, 46.51, 146.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44424,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 34.82,,CLAIM ADJUSTMENT 3, 73.72,OTHER, 34.82, 131.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44425,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 35.93,,CLAIM ADJUSTMENT 3, 75.45,OTHER, 35.93, 134.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44426,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 33.53,,CLAIM ADJUSTMENT 3, 121.64,OTHER, 33.53, 228.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44427,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.34,,CLAIM ADJUSTMENT 3, 69.17,OTHER, 7.34, 135.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44428,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.19,,CLAIM ADJUSTMENT 3, 124.67,OTHER, 24.19, 238.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44429,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.63,,CLAIM ADJUSTMENT 3, 76.46,OTHER, 19.63, 144.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44430,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 21.17,,CLAIM ADJUSTMENT 3, 71.48,OTHER, 21.17, 133.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44431,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44432,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44433,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44434,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44435,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.39,,CLAIM ADJUSTMENT 3, 90.70,OTHER, 13.39, 415.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44436,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 23.70,,CLAIM ADJUSTMENT 3, 64.96,OTHER, 23.70, 119.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44437,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.54,,CLAIM ADJUSTMENT 3, 34.98,OTHER, 11.54, 64.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44438,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.54,,CLAIM ADJUSTMENT 3, 203.52,OTHER, 37.54, 390.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44439,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 25.39,,CLAIM ADJUSTMENT 3, 61.71,OTHER, 25.39, 111.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44440,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 25.64,OTHER, 5.66, 48.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44441,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 25.64,OTHER, 5.66, 48.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44442,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 25.64,OTHER, 5.66, 48.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44443,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 28.32,OTHER, 5.66, 54.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44444,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 28.32,OTHER, 5.66, 54.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44445,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 28.32,OTHER, 5.66, 54.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44446,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.66,,CLAIM ADJUSTMENT 3, 14.14,OTHER, 5.66, 25.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44447,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 64.46,OTHER, 6.84, 126.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44448,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 64.46,OTHER, 6.84, 126.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44449,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.97,,CLAIM ADJUSTMENT 3, 57.91,OTHER, 13.97, 109.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44450,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 10.37,,CLAIM ADJUSTMENT 3, 37.55,OTHER, 10.37, 70.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44451,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 26.76,,CLAIM ADJUSTMENT 3, 94.73,OTHER, 26.76, 177.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44452,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 26.76,,CLAIM ADJUSTMENT 3, 94.73,OTHER, 26.76, 177.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44453,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 94.52,OTHER, 26.66, 176.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44454,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 26.66,,CLAIM ADJUSTMENT 3, 94.52,OTHER, 26.66, 176.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44455,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.12,,CLAIM ADJUSTMENT 3, 67.05,OTHER, 18.12, 125.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44456,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 31.62,,CLAIM ADJUSTMENT 3, 74.92,OTHER, 31.62, 135.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44457,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 48.30,OTHER, 13.98, 90.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44458,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 48.30,OTHER, 13.98, 90.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44459,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.98,,CLAIM ADJUSTMENT 3, 48.30,OTHER, 13.98, 90.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44460,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 25.80,,CLAIM ADJUSTMENT 3, 99.83,OTHER, 25.80, 188.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44461,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44462,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44463,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44464,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44465,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44466,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 136.44,OTHER, 16.61, 294.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44467,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.86,,CLAIM ADJUSTMENT 3, 128.28,OTHER, 24.86, 290.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44468,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.86,,CLAIM ADJUSTMENT 3, 128.28,OTHER, 24.86, 290.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44469,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.86,,CLAIM ADJUSTMENT 3, 128.28,OTHER, 24.86, 290.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44470,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 25.93,OTHER, 18.49, 42.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44471,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.46,,CLAIM ADJUSTMENT 3, 69.04,OTHER, 16.46, 130.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44472,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 43.88,OTHER, 9.31, 83.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44473,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 43.88,OTHER, 9.31, 83.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44474,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 43.88,OTHER, 9.31, 83.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44475,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44476,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44477,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44478,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.59,,CLAIM ADJUSTMENT 3, 53.98,OTHER, 12.59, 102.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44479,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.66,,CLAIM ADJUSTMENT 3, 70.04,OTHER, 16.66, 132.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44480,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 8.70,,CLAIM ADJUSTMENT 3, 51.00,OTHER, 8.70, 111.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44481,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 8.70,,CLAIM ADJUSTMENT 3, 51.00,OTHER, 8.70, 111.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44482,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.42,,CLAIM ADJUSTMENT 3, 85.45,OTHER, 18.42, 162.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44483,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 28.37,,CLAIM ADJUSTMENT 3, 68.77,OTHER, 28.37, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44484,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.44,,CLAIM ADJUSTMENT 3, 54.77,OTHER, 17.44, 101.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44485,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.44,,CLAIM ADJUSTMENT 3, 54.77,OTHER, 17.44, 101.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44486,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.92,,CLAIM ADJUSTMENT 3, 60.48,OTHER, 9.92, 116.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44487,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.92,,CLAIM ADJUSTMENT 3, 60.48,OTHER, 9.92, 116.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44488,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 66.68,,CLAIM ADJUSTMENT 3, 149.05,OTHER, 66.68, 267.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44489,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 49.24,,CLAIM ADJUSTMENT 3, 43.46,OTHER, 27.95, 63.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44490,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 15.12,,CLAIM ADJUSTMENT 3, 43.01,OTHER, 15.12, 79.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44491,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 15.12,,CLAIM ADJUSTMENT 3, 43.01,OTHER, 15.12, 79.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44492,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.65,,CLAIM ADJUSTMENT 3, 40.64,OTHER, 9.65, 76.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44493,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 34.72,,CLAIM ADJUSTMENT 3, 204.04,OTHER, 34.72, 392.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44494,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 23.41,,CLAIM ADJUSTMENT 3, 57.49,OTHER, 23.41, 104.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44495,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 159.56,OTHER, 24.40, 308.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44496,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 159.56,OTHER, 24.40, 308.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44497,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.60,,CLAIM ADJUSTMENT 3, 74.79,OTHER, 18.60, 163.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44498,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.60,,CLAIM ADJUSTMENT 3, 74.79,OTHER, 18.60, 163.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44499,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 56.53,,CLAIM ADJUSTMENT 3, 120.40,OTHER, 56.53, 214.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44500,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 56.53,,CLAIM ADJUSTMENT 3, 120.40,OTHER, 56.53, 214.62,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44501,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 30.54,,CLAIM ADJUSTMENT 3, 110.95,OTHER, 30.54, 208.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44502,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.52,,CLAIM ADJUSTMENT 3, 54.17,OTHER, 9.52, 104.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44503,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.82,,CLAIM ADJUSTMENT 3, 44.45,OTHER, 9.82, 84.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44504,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.82,,CLAIM ADJUSTMENT 3, 44.45,OTHER, 9.82, 84.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44505,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.81,,CLAIM ADJUSTMENT 3, 86.15,OTHER, 20.81, 162.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44506,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 59.45,,CLAIM ADJUSTMENT 3, 147.00,OTHER, 59.45, 266.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44507,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 59.45,,CLAIM ADJUSTMENT 3, 147.00,OTHER, 59.45, 266.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44508,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 27.89,,CLAIM ADJUSTMENT 3, 43.75,OTHER, 27.89, 74.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44509,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 28.27,,CLAIM ADJUSTMENT 3, 186.61,OTHER, 28.27, 361.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44510,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 45.87,OTHER, 7.46, 92.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44511,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 45.87,OTHER, 7.46, 92.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44512,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.83,,CLAIM ADJUSTMENT 3, 35.19,OTHER, 6.83, 67.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44513,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.83,,CLAIM ADJUSTMENT 3, 35.19,OTHER, 6.83, 67.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44514,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.85,,CLAIM ADJUSTMENT 3, 28.87,OTHER, 6.85, 54.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44515,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.82,,CLAIM ADJUSTMENT 3, 13.83,OTHER, 6.82, 24.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44516,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 21.01,,CLAIM ADJUSTMENT 3, 45.56,OTHER, 21.01, 81.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44517,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 30.04,,CLAIM ADJUSTMENT 3, 92.72,OTHER, 30.04, 171.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44518,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 30.04,,CLAIM ADJUSTMENT 3, 92.72,OTHER, 30.04, 171.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44519,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 39.19,,CLAIM ADJUSTMENT 3, 102.79,OTHER, 39.19, 187.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44520,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 27.91,,CLAIM ADJUSTMENT 3, 97.17,OTHER, 27.91, 181.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44521,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 26.48,,CLAIM ADJUSTMENT 3, 90.21,OTHER, 26.48, 174.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44522,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 26.48,,CLAIM ADJUSTMENT 3, 90.21,OTHER, 26.48, 174.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44523,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 26.48,,CLAIM ADJUSTMENT 3, 93.39,OTHER, 26.48, 174.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44524,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 24.66,OTHER, 5.28, 46.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44525,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 24.66,OTHER, 5.28, 46.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44526,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 57.84,OTHER, 5.28, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44527,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 57.84,OTHER, 5.28, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44528,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.28,,CLAIM ADJUSTMENT 3, 57.84,OTHER, 5.28, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44529,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.76,,CLAIM ADJUSTMENT 3, 41.90,OTHER, 5.76, 83.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44530,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.76,,CLAIM ADJUSTMENT 3, 41.90,OTHER, 5.76, 83.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44531,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.76,,CLAIM ADJUSTMENT 3, 41.90,OTHER, 5.76, 83.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44532,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 144.06,OTHER, 15.47, 390.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44533,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 144.06,OTHER, 15.47, 390.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44534,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 25.68,,CLAIM ADJUSTMENT 3, 141.59,OTHER, 25.68, 394.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44535,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 25.68,,CLAIM ADJUSTMENT 3, 141.59,OTHER, 25.68, 394.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44536,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 38.44,,CLAIM ADJUSTMENT 3, 136.35,OTHER, 38.44, 255.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44537,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 40.46,,CLAIM ADJUSTMENT 3, 103.27,OTHER, 40.46, 187.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44538,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 31.67,,CLAIM ADJUSTMENT 3, 76.88,OTHER, 31.67, 139.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44539,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 29.15,,CLAIM ADJUSTMENT 3, 178.83,OTHER, 29.15, 344.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44540,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 31.30,,CLAIM ADJUSTMENT 3, 88.43,OTHER, 31.30, 162.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44541,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.92,,CLAIM ADJUSTMENT 3, 30.02,OTHER, 6.92, 56.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44542,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.92,,CLAIM ADJUSTMENT 3, 30.02,OTHER, 6.92, 56.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44543,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.28,,CLAIM ADJUSTMENT 3, 34.17,OTHER, 7.28, 88.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44544,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.28,,CLAIM ADJUSTMENT 3, 34.17,OTHER, 7.28, 88.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44545,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.28,,CLAIM ADJUSTMENT 3, 34.17,OTHER, 7.28, 88.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44546,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 30.61,,CLAIM ADJUSTMENT 3, 180.72,OTHER, 30.61, 348.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44547,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.66,,CLAIM ADJUSTMENT 3, 302.95,OTHER, 11.66, 602.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44548,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 36.67,,CLAIM ADJUSTMENT 3, 81.90,OTHER, 36.67, 146.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44549,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44550,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44551,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44552,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 123.12,OTHER, 37.16, 229.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44553,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 30.58,,CLAIM ADJUSTMENT 3, 86.80,OTHER, 30.58, 159.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44554,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 30.58,,CLAIM ADJUSTMENT 3, 86.80,OTHER, 30.58, 159.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44555,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 23.12,,CLAIM ADJUSTMENT 3, 107.35,OTHER, 23.12, 204.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44556,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 23.12,,CLAIM ADJUSTMENT 3, 107.35,OTHER, 23.12, 204.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44557,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.89,,CLAIM ADJUSTMENT 3, 53.27,OTHER, 9.89, 102.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44558,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.89,,CLAIM ADJUSTMENT 3, 53.27,OTHER, 9.89, 102.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44559,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.98,,CLAIM ADJUSTMENT 3, 75.95,OTHER, 12.98, 146.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44560,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.98,,CLAIM ADJUSTMENT 3, 75.95,OTHER, 12.98, 146.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44561,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.98,,CLAIM ADJUSTMENT 3, 75.95,OTHER, 12.98, 146.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44562,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 21.29,,CLAIM ADJUSTMENT 3, 51.95,OTHER, 21.29, 94.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44563,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.19,,CLAIM ADJUSTMENT 3, 73.53,OTHER, 24.19, 136.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44564,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 73.24,,CLAIM ADJUSTMENT 3, 154.17,OTHER, 73.24, 274.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44565,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 73.24,,CLAIM ADJUSTMENT 3, 154.17,OTHER, 73.24, 274.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44566,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.42,,CLAIM ADJUSTMENT 3, 49.79,OTHER, 20.42, 90.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44567,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 38.32,OTHER, 7.46, 73.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44568,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.63,,CLAIM ADJUSTMENT 3, 35.99,OTHER, 7.63, 68.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44569,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.37,,CLAIM ADJUSTMENT 3, 58.51,OTHER, 18.37, 108.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44570,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 8.27,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 8.27, 74.59,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44571,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.42,,CLAIM ADJUSTMENT 3, 79.41,OTHER, 20.42, 149.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44572,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.42,,CLAIM ADJUSTMENT 3, 79.41,OTHER, 20.42, 149.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44573,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 78.90,OTHER, 24.40, 146.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44574,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.40,,CLAIM ADJUSTMENT 3, 78.90,OTHER, 24.40, 146.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44575,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 22.69,,CLAIM ADJUSTMENT 3, 126.89,OTHER, 22.69, 243.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44576,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.95,,CLAIM ADJUSTMENT 3, 82.99,OTHER, 17.95, 157.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44577,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.95,,CLAIM ADJUSTMENT 3, 82.99,OTHER, 17.95, 157.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44578,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.69,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 5.69, 75.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44579,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.69,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 5.69, 75.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44580,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.69,,CLAIM ADJUSTMENT 3, 39.13,OTHER, 5.69, 75.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44581,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 8.00,,CLAIM ADJUSTMENT 3, 22.60,OTHER, 8.00, 41.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44582,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 8.00,,CLAIM ADJUSTMENT 3, 22.60,OTHER, 8.00, 41.53,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44583,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.50,,CLAIM ADJUSTMENT 3, 31.87,OTHER, 6.50, 60.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44584,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.32,,CLAIM ADJUSTMENT 3, 39.10,OTHER, 7.32, 74.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44585,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.72,,CLAIM ADJUSTMENT 3, 76.33,OTHER, 16.72, 145.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44586,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.75,,CLAIM ADJUSTMENT 3, 103.71,OTHER, 19.75, 198.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44587,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.40,,CLAIM ADJUSTMENT 3, 56.68,OTHER, 16.40, 105.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44588,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.40,,CLAIM ADJUSTMENT 3, 56.68,OTHER, 16.40, 105.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44589,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.40,,CLAIM ADJUSTMENT 3, 56.68,OTHER, 16.40, 105.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44590,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 29.96, 157.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44591,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 21.67,,CLAIM ADJUSTMENT 3, 97.04,OTHER, 21.67, 184.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44592,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.94,,CLAIM ADJUSTMENT 3, 42.88,OTHER, 6.94, 82.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44593,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.47,,CLAIM ADJUSTMENT 3, 43.80,OTHER, 5.47, 85.29,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44594,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 17.85,OTHER, 3.41, 34.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44595,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 17.85,OTHER, 3.41, 34.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44596,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 21.46,OTHER, 3.41, 41.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44597,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 3.41,,CLAIM ADJUSTMENT 3, 21.46,OTHER, 3.41, 41.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44598,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 22.31,OTHER, .01, 84.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44599,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.18,,CLAIM ADJUSTMENT 3, 22.31,OTHER, .01, 84.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44600,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.31,,CLAIM ADJUSTMENT 3, 44.71,OTHER, 9.31, 85.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44601,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.75,,CLAIM ADJUSTMENT 3, 37.65,OTHER, 5.75, 72.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44602,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.75,,CLAIM ADJUSTMENT 3, 37.65,OTHER, 5.75, 72.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44603,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 3.66,,CLAIM ADJUSTMENT 3, 19.92,OTHER, 3.66, 38.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44604,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.46,,CLAIM ADJUSTMENT 3, 32.63,OTHER, 6.46, 62.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44605,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 25.78,,CLAIM ADJUSTMENT 3, 96.77,OTHER, 25.78, 181.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44606,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 33.04,,CLAIM ADJUSTMENT 3, 129.31,OTHER, 33.04, 243.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44607,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.06,,CLAIM ADJUSTMENT 3, 130.54,OTHER, 17.06, 253.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44608,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.93,,CLAIM ADJUSTMENT 3, 98.34,OTHER, 19.93, 187.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44609,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 22.06,,CLAIM ADJUSTMENT 3, 89.00,OTHER, 22.06, 168.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44610,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 14.66,,CLAIM ADJUSTMENT 3, 98.22,OTHER, 14.66, 190.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44611,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.99,,CLAIM ADJUSTMENT 3, 54.63,OTHER, 13.99, 102.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44612,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 27.00,,CLAIM ADJUSTMENT 3, 70.40,OTHER, 27.00, 128.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44613,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 29.86,OTHER, 6.18, 57.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44614,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 29.86,OTHER, 6.18, 57.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44615,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 29.86,OTHER, 6.18, 57.09,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44616,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44617,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44618,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44619,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.18,,CLAIM ADJUSTMENT 3, 14.17,OTHER, 6.18, 25.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44620,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 41.60,OTHER, 6.14, 80.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44621,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 3.89,,CLAIM ADJUSTMENT 3, 26.32,OTHER, 3.89, 50.96,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44622,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.93,,CLAIM ADJUSTMENT 3, 36.35,OTHER, 7.93, 69.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44623,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 8.65,,CLAIM ADJUSTMENT 3, 61.85,OTHER, 8.65, 166.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44624,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 8.65,,CLAIM ADJUSTMENT 3, 61.85,OTHER, 8.65, 166.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44625,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.26,,CLAIM ADJUSTMENT 3, 76.67,OTHER, 11.26, 148.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44626,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44627,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44628,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44629,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44630,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44631,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44632,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44633,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44634,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44635,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44636,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44637,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44638,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44639,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44640,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44641,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44642,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44643,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44644,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44645,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44646,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44647,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44648,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44649,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44650,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44651,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44652,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44653,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44654,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44655,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44656,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44657,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44658,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44659,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44660,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44661,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44662,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44663,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44664,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44665,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44666,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44667,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44668,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44669,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44670,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44671,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44672,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44673,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44674,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44675,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44676,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44677,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44678,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44679,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44680,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44681,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44682,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44683,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44684,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44685,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44686,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44687,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.51,,CLAIM ADJUSTMENT 3, 44.89,OTHER, 7.51, 1164.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44688,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 26.45,,CLAIM ADJUSTMENT 3, 189.29,OTHER, 26.45, 367.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44689,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 14.46,,CLAIM ADJUSTMENT 3, 115.17,OTHER, 14.46, 224.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44690,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.41,,CLAIM ADJUSTMENT 3, 91.70,OTHER, 17.41, 220.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44691,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.41,,CLAIM ADJUSTMENT 3, 91.70,OTHER, 17.41, 220.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44692,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.07,,CLAIM ADJUSTMENT 3, 48.91,OTHER, 16.07, 90.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44693,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 10.51,,CLAIM ADJUSTMENT 3, 45.23,OTHER, 10.51, 85.75,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44694,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 17.08,OTHER, 7.46, 30.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44695,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 17.08,OTHER, 7.46, 30.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44696,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.65,,CLAIM ADJUSTMENT 3, 59.25,OTHER, 18.65, 110.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44697,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 36.65,,CLAIM ADJUSTMENT 3, 93.98,OTHER, 36.65, 171.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44698,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 36.65,,CLAIM ADJUSTMENT 3, 137.37,OTHER, 36.65, 258.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44699,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 23.14,,CLAIM ADJUSTMENT 3, 78.46,OTHER, 23.14, 146.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44700,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.28,,CLAIM ADJUSTMENT 3, 67.64,OTHER, 17.28, 127.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44701,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.28,,CLAIM ADJUSTMENT 3, 67.64,OTHER, 17.28, 127.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44702,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 29.26,,CLAIM ADJUSTMENT 3, 77.69,OTHER, 29.26, 141.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44703,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.65,,CLAIM ADJUSTMENT 3, 63.19,OTHER, 18.65, 117.89,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44704,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.79,,CLAIM ADJUSTMENT 3, 65.88,OTHER, 19.79, 127.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44705,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.79,,CLAIM ADJUSTMENT 3, 65.88,OTHER, 19.79, 127.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44706,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44707,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44708,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44709,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44710,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44711,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 25.82,,CLAIM ADJUSTMENT 3, 75.23,OTHER, 25.82, 138.79,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44712,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 68.02,OTHER, 17.35, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44713,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 68.02,OTHER, 17.35, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44714,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 68.02,OTHER, 17.35, 155.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44715,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 120.82,OTHER, 17.35, 238.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44716,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 120.82,OTHER, 17.35, 238.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44717,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 14.46,,CLAIM ADJUSTMENT 3, 15.65,OTHER, 10.75, 24.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44718,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 80.94,OTHER, 29.96, 150.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44719,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 80.94,OTHER, 29.96, 150.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44720,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 85.12,OTHER, 29.96, 156.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44721,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 29.96,,CLAIM ADJUSTMENT 3, 103.45,OTHER, 29.96, 193.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44722,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.97,,CLAIM ADJUSTMENT 3, 125.05,OTHER, 24.97, 345.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44723,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.97,,CLAIM ADJUSTMENT 3, 125.05,OTHER, 24.97, 345.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44724,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 50.54,OTHER, 7.46, 97.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44725,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 32.17,,CLAIM ADJUSTMENT 3, 88.87,OTHER, 32.17, 162.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44726,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 30.83,,CLAIM ADJUSTMENT 3, 66.43,OTHER, 30.83, 118.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44727,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 21.72,,CLAIM ADJUSTMENT 3, 57.43,OTHER, 21.72, 104.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44728,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 33.95,,CLAIM ADJUSTMENT 3, 265.06,OTHER, 33.95, 515.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44729,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 80.97,OTHER, 38.57, 144.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44730,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 80.97,OTHER, 38.57, 144.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44731,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 54.34,,CLAIM ADJUSTMENT 3, 111.82,OTHER, 54.34, 198.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44732,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 67.64,,CLAIM ADJUSTMENT 3, 176.22,OTHER, 67.64, 321.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44733,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 88.05,OTHER, 38.57, 158.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44734,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 38.57,,CLAIM ADJUSTMENT 3, 88.05,OTHER, 38.57, 158.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44735,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.84,,CLAIM ADJUSTMENT 3, 68.73,OTHER, 13.84, 131.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44736,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.95,,CLAIM ADJUSTMENT 3, 96.09,OTHER, 20.95, 205.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44737,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.95,,CLAIM ADJUSTMENT 3, 96.09,OTHER, 20.95, 205.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44738,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.60,,CLAIM ADJUSTMENT 3, 70.10,OTHER, 19.60, 131.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44739,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 8.16,,CLAIM ADJUSTMENT 3, 46.86,OTHER, 8.16, 90.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44740,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 8.16,,CLAIM ADJUSTMENT 3, 46.86,OTHER, 8.16, 90.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44741,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 89.24,,CLAIM ADJUSTMENT 3, 191.67,OTHER, 89.24, 342.02,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44742,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.33,,CLAIM ADJUSTMENT 3, 12.31,OTHER, 8.04, 18.33,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44743,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.34,,CLAIM ADJUSTMENT 3, 18.56,OTHER, 6.34, 34.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44744,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 21.67,,CLAIM ADJUSTMENT 3, 36.21,OTHER, 21.67, 62.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44745,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 14.66,,CLAIM ADJUSTMENT 3, 55.25,OTHER, 14.66, 103.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44746,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.58,,CLAIM ADJUSTMENT 3, 40.13,OTHER, 18.58, 71.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44747,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.00,,CLAIM ADJUSTMENT 3, 66.54,OTHER, 19.00, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44748,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.53,,CLAIM ADJUSTMENT 3, 88.38,OTHER, 24.53, 165.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44749,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.53,,CLAIM ADJUSTMENT 3, 88.38,OTHER, 24.53, 165.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44750,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.53,,CLAIM ADJUSTMENT 3, 88.38,OTHER, 24.53, 165.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44751,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.29,,CLAIM ADJUSTMENT 3, 26.75,OTHER, 17.29, 45.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44752,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.51,,CLAIM ADJUSTMENT 3, 91.08,OTHER, 16.51, 254.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44753,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.51,,CLAIM ADJUSTMENT 3, 91.08,OTHER, 16.51, 254.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44754,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 50.83,OTHER, 20.72, 92.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44755,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 59.00,OTHER, 24.26, 106.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44756,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 22.02,,CLAIM ADJUSTMENT 3, 64.46,OTHER, 22.02, 118.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44757,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 26.12,,CLAIM ADJUSTMENT 3, 59.50,OTHER, 26.12, 106.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44758,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 26.12,,CLAIM ADJUSTMENT 3, 59.50,OTHER, 26.12, 106.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44759,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 71.41,OTHER, 24.26, 179.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44760,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 71.41,OTHER, 24.26, 179.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44761,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 24.26,,CLAIM ADJUSTMENT 3, 71.41,OTHER, 24.26, 179.32,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44762,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 27.86,,CLAIM ADJUSTMENT 3, 66.70,OTHER, 27.86, 120.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44763,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 27.86,,CLAIM ADJUSTMENT 3, 66.70,OTHER, 27.86, 120.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44764,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 43.51,OTHER, 20.72, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44765,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.00,,CLAIM ADJUSTMENT 3, 47.68,OTHER, 19.00, 86.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44766,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 27.86,,CLAIM ADJUSTMENT 3, 58.39,OTHER, 27.86, 103.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44767,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.86,,CLAIM ADJUSTMENT 3, 77.47,OTHER, 19.86, 145.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44768,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.74,,CLAIM ADJUSTMENT 3, 62.50,OTHER, 19.74, 116.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44769,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 46.75,OTHER, 17.35, 85.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44770,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.94,,CLAIM ADJUSTMENT 3, 41.14,OTHER, 16.94, 74.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44771,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 15.47,,CLAIM ADJUSTMENT 3, 67.08,OTHER, 15.47, 127.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44772,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.84,,CLAIM ADJUSTMENT 3, 50.52,OTHER, 17.84, 92.87,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44773,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.21,,CLAIM ADJUSTMENT 3, 28.18,OTHER, 16.21, 48.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44774,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.79,,CLAIM ADJUSTMENT 3, 52.54,OTHER, 18.79, 96.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44775,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.79,,CLAIM ADJUSTMENT 3, 52.54,OTHER, 18.79, 96.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44776,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.07,,CLAIM ADJUSTMENT 3, 41.16,OTHER, 19.07, 73.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44777,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 46.11,OTHER, 20.72, 82.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44778,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 46.11,OTHER, 20.72, 82.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44779,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.72,,CLAIM ADJUSTMENT 3, 46.11,OTHER, 20.72, 82.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44780,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 48.00,OTHER, 18.55, 88.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44781,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 48.00,OTHER, 18.55, 88.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44782,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 48.00,OTHER, 18.55, 88.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44783,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.07,,CLAIM ADJUSTMENT 3, 49.38,OTHER, 19.07, 89.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44784,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 80.11,OTHER, 18.55, 151.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44785,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 80.11,OTHER, 18.55, 151.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44786,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.55,,CLAIM ADJUSTMENT 3, 361.76,OTHER, 18.55, 717.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44787,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 20.54,,CLAIM ADJUSTMENT 3, 161.64,OTHER, 20.54, 314.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44788,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 92.44,,CLAIM ADJUSTMENT 3, 158.63,OTHER, 92.44, 274.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44789,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 92.44,,CLAIM ADJUSTMENT 3, 158.63,OTHER, 92.44, 274.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44790,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 14.06,,CLAIM ADJUSTMENT 3, 78.01,OTHER, 14.06, 149.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44791,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 14.06,,CLAIM ADJUSTMENT 3, 78.01,OTHER, 14.06, 149.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44792,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 14.06,,CLAIM ADJUSTMENT 3, 78.01,OTHER, 14.06, 149.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44793,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 152.44,OTHER, 102.77, 234.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44794,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 251.30,,CLAIM ADJUSTMENT 3, 270.23,OTHER, 185.27, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44795,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 251.30,,CLAIM ADJUSTMENT 3, 270.23,OTHER, 185.27, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44796,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 251.30,,CLAIM ADJUSTMENT 3, 270.23,OTHER, 185.27, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44797,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44798,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44799,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44800,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44801,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 81.76,OTHER, 7.76, 160.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44802,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.46,,CLAIM ADJUSTMENT 3, 146.86,OTHER, 7.46, 291.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44803,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 54.74,OTHER, 4.31, 107.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44804,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 54.74,OTHER, 4.31, 107.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44805,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 54.74,OTHER, 4.31, 107.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44806,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 44.77,OTHER, 4.31, 89.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44807,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 44.77,OTHER, 4.31, 89.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44808,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 4.31,,CLAIM ADJUSTMENT 3, 44.77,OTHER, 4.31, 89.26,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44809,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.52,,CLAIM ADJUSTMENT 3, 205.30,OTHER, 5.52, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44810,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.52,,CLAIM ADJUSTMENT 3, 205.30,OTHER, 5.52, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44811,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.52,,CLAIM ADJUSTMENT 3, 205.30,OTHER, 5.52, 422.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44812,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.16,,CLAIM ADJUSTMENT 3, 70.78,OTHER, 11.16, 136.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44813,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.16,,CLAIM ADJUSTMENT 3, 70.78,OTHER, 11.16, 136.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44814,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44815,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44816,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44817,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44818,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44819,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 150.08,,CLAIM ADJUSTMENT 3, 325.90,OTHER, 150.08, 582.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44820,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 35.20,,CLAIM ADJUSTMENT 3, 76.50,OTHER, 35.20, 136.71,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44821,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 91.25,,CLAIM ADJUSTMENT 3, 149.18,OTHER, 91.25, 255.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44822,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 14.86,,CLAIM ADJUSTMENT 3, 81.41,OTHER, 14.86, 156.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44823,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 14.86,,CLAIM ADJUSTMENT 3, 81.41,OTHER, 14.86, 156.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44824,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.60,,CLAIM ADJUSTMENT 3, 30.76,OTHER, 13.60, 55.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44825,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.41,,CLAIM ADJUSTMENT 3, 72.64,OTHER, 12.41, 139.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44826,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.41,,CLAIM ADJUSTMENT 3, 72.64,OTHER, 12.41, 139.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44827,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.63,,CLAIM ADJUSTMENT 3, 78.26,OTHER, 13.63, 150.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44828,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 13.63,,CLAIM ADJUSTMENT 3, 78.26,OTHER, 13.63, 150.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44829,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 78.99,OTHER, 11.64, 152.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44830,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 46.77,OTHER, 11.64, 88.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44831,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 46.77,OTHER, 11.64, 88.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44832,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.64,,CLAIM ADJUSTMENT 3, 46.77,OTHER, 11.64, 88.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44833,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 9.55,,CLAIM ADJUSTMENT 3, 40.96,OTHER, 9.55, 77.65,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44834,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.62,,CLAIM ADJUSTMENT 3, 44.68,OTHER, 11.62, 84.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44835,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.62,,CLAIM ADJUSTMENT 3, 44.68,OTHER, 11.62, 84.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44836,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.62,,CLAIM ADJUSTMENT 3, 44.68,OTHER, 11.62, 84.11,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44837,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.65,,CLAIM ADJUSTMENT 3, 82.26,OTHER, 11.65, 159.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44838,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 11.65,,CLAIM ADJUSTMENT 3, 82.26,OTHER, 11.65, 159.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44839,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.11,,CLAIM ADJUSTMENT 3, 74.74,OTHER, 12.11, 144.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44840,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 15.55,,CLAIM ADJUSTMENT 3, 91.00,OTHER, 15.55, 175.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44841,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.82,,CLAIM ADJUSTMENT 3, 68.31,OTHER, 12.82, 130.97,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44842,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 17.74,OTHER, 6.84, 32.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44843,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 10.78,,CLAIM ADJUSTMENT 3, 22.99,OTHER, 10.78, 40.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44844,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.84,,CLAIM ADJUSTMENT 3, 29.95,OTHER, 6.84, 56.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44845,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 12.46,,CLAIM ADJUSTMENT 3, 42.41,OTHER, 12.46, 79.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44846,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44847,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44848,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44849,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44850,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.14,,CLAIM ADJUSTMENT 3, 27.61,OTHER, 6.14, 55.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44851,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 38.14,OTHER, 7.76, 72.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44852,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 7.76,,CLAIM ADJUSTMENT 3, 38.14,OTHER, 7.76, 72.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44853,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 8.38,,CLAIM ADJUSTMENT 3, 28.29,OTHER, 8.38, 52.77,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44854,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 28.16,,CLAIM ADJUSTMENT 3, 68.72,OTHER, 28.16, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44855,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.26,,CLAIM ADJUSTMENT 3, 299.39,OTHER, 17.26, 592.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44856,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 14.88,,CLAIM ADJUSTMENT 3, 40.67,OTHER, 14.88, 74.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44857,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 16.61,,CLAIM ADJUSTMENT 3, 43.08,OTHER, 16.61, 78.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44858,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 19.08,,CLAIM ADJUSTMENT 3, 121.25,OTHER, 19.08, 234.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44859,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 28.87,,CLAIM ADJUSTMENT 3, 68.89,OTHER, 28.87, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44860,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 106.28,OTHER, 50.53, 189.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44861,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 106.28,OTHER, 50.53, 189.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44862,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 53.66,,CLAIM ADJUSTMENT 3, 107.02,OTHER, 53.66, 189.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44863,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 53.66,,CLAIM ADJUSTMENT 3, 107.02,OTHER, 53.66, 189.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44864,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 53.66,,CLAIM ADJUSTMENT 3, 107.02,OTHER, 53.66, 189.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44865,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 198.86,OTHER, 61.69, 369.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44866,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 198.86,OTHER, 61.69, 369.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44867,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44868,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 221.47,OTHER, 61.69, 415.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44869,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 76.43,OTHER, 50.53, 129.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44870,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 122.54,,CLAIM ADJUSTMENT 3, 265.03,OTHER, 122.54, 473.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44871,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 106.28,OTHER, 50.53, 189.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44872,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44873,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44874,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 600.16,,CLAIM ADJUSTMENT 3, 445.68,OTHER, 266.63, 607.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44875,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44876,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44877,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44878,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 193.99,OTHER, 50.53, 365.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44879,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 193.99,OTHER, 50.53, 365.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44880,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44881,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 173.66,OTHER, 50.53, 324.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44882,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 28.87,,CLAIM ADJUSTMENT 3, 68.89,OTHER, 28.87, 124.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44883,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 204.22,OTHER, 50.53, 599.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44884,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 50.53,,CLAIM ADJUSTMENT 3, 204.22,OTHER, 50.53, 599.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44885,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 146.52,OTHER, 61.69, 264.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44886,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 146.52,OTHER, 61.69, 264.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44887,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 23.83,,CLAIM ADJUSTMENT 3, 62.25,OTHER, 23.83, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44888,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 23.83,,CLAIM ADJUSTMENT 3, 62.25,OTHER, 23.83, 113.55,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44889,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.86,,CLAIM ADJUSTMENT 3, 43.07,OTHER, 18.86, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44890,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.86,,CLAIM ADJUSTMENT 3, 43.07,OTHER, 18.86, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44891,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 23.81,,CLAIM ADJUSTMENT 3, 44.25,OTHER, 23.81, 77.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44892,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 23.81,,CLAIM ADJUSTMENT 3, 17.88,OTHER, 10.75, 24.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44893,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 23.14,,CLAIM ADJUSTMENT 3, 100.14,OTHER, 23.14, 189.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44894,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 370.73,,CLAIM ADJUSTMENT 3, 800.72,OTHER, 370.73, 1429.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44895,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 370.73,,CLAIM ADJUSTMENT 3, 800.72,OTHER, 370.73, 1429.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44896,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 38.32,,CLAIM ADJUSTMENT 3, 59.91,OTHER, 38.32, 101.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44897,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 38.32,,CLAIM ADJUSTMENT 3, 59.91,OTHER, 38.32, 101.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44898,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 97.97,,CLAIM ADJUSTMENT 3, 294.34,OTHER, 97.97, 543.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44899,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44900,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44901,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.79,,CLAIM ADJUSTMENT 3, 16.75,OTHER, 6.79, 30.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44902,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 6.79,,CLAIM ADJUSTMENT 3, 16.75,OTHER, 6.79, 30.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44903,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 8.06,,CLAIM ADJUSTMENT 3, 56.81,OTHER, 8.06, 110.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44904,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 10.56,,CLAIM ADJUSTMENT 3, 39.98,OTHER, 10.56, 75.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44905,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 17.35,,CLAIM ADJUSTMENT 3, 41.73,OTHER, 17.35, 75.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44906,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44907,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 63.90,OTHER, 37.34, 110.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44908,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 63.90,OTHER, 37.34, 110.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44909,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 23.30,OTHER, 12.69, 37.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44910,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 37.95,OTHER, 25.59, 58.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44911,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 23.42,OTHER, 12.79, 37.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44912,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44913,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44914,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 315.54,,CLAIM ADJUSTMENT 3, 149.84,OTHER, 65.79, 315.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44915,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 315.54,,CLAIM ADJUSTMENT 3, 149.84,OTHER, 65.79, 315.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44916,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44917,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 71.34,,CLAIM ADJUSTMENT 3, 41.40,OTHER, 21.50, 71.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44918,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 71.34,,CLAIM ADJUSTMENT 3, 41.40,OTHER, 21.50, 71.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44919,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 280.30,,CLAIM ADJUSTMENT 3, 356.50,OTHER, 255.16, 581.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44920,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 345.38,,CLAIM ADJUSTMENT 3, 687.64,OTHER, 345.38, 1214.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44921,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44922,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44923,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44924,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 77.65,,CLAIM ADJUSTMENT 3, 60.00,OTHER, 36.55, 83.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44925,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 48.79,,CLAIM ADJUSTMENT 3, 36.74,OTHER, 22.12, 50.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44926,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 48.79,,CLAIM ADJUSTMENT 3, 36.74,OTHER, 22.12, 50.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44927,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44928,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44929,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44930,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44931,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44932,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44933,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44934,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44935,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44936,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44937,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44938,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 143.83,,CLAIM ADJUSTMENT 3, 111.30,OTHER, 67.85, 154.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44939,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 143.83,,CLAIM ADJUSTMENT 3, 111.30,OTHER, 67.85, 154.64,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44940,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44941,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44942,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 89.44,,CLAIM ADJUSTMENT 3, 104.75,OTHER, 73.49, 167.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44943,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 89.44,,CLAIM ADJUSTMENT 3, 104.75,OTHER, 73.49, 167.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44944,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 33.16,,CLAIM ADJUSTMENT 3, 12.78,OTHER, 4.30, 33.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44945,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 5.09,,CLAIM ADJUSTMENT 3, 17.36,OTHER, 5.09, 32.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44946,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 184.48,OTHER, 130.68, 297.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44947,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 202.35,OTHER, 146.42, 333.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44948,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 113.95,,CLAIM ADJUSTMENT 3, 99.37,OTHER, 63.61, 144.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44949,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 59.56,,CLAIM ADJUSTMENT 3, 88.44,OTHER, 59.56, 149.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44950,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 131.72,OTHER, 84.22, 191.95,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44951,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 96.67,,CLAIM ADJUSTMENT 3, 117.05,OTHER, 82.81, 188.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44952,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 179.75,OTHER, 126.51, 288.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44953,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 143.72,,CLAIM ADJUSTMENT 3, 158.52,OTHER, 109.46, 249.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44954,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 151.51,,CLAIM ADJUSTMENT 3, 186.21,OTHER, 132.20, 301.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44955,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 50.93,,CLAIM ADJUSTMENT 3, 83.96,OTHER, 50.93, 144.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44956,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 216.78,,CLAIM ADJUSTMENT 3, 167.44,OTHER, 102.00, 232.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44957,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 216.78,,CLAIM ADJUSTMENT 3, 172.28,OTHER, 106.26, 242.17,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44958,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 87.35,,CLAIM ADJUSTMENT 3, 49.86,OTHER, 25.59, 87.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44959,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 85.51,,CLAIM ADJUSTMENT 3, 141.43,OTHER, 85.51, 242.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44960,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 69.71,OTHER, 45.42, 103.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44961,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 177.65,OTHER, 120.47, 274.57,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44962,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 189.46,OTHER, 130.87, 298.25,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44963,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 279.93,OTHER, 171.54, 479.83,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44964,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 171.54,,CLAIM ADJUSTMENT 3, 265.00,OTHER, 171.54, 449.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44965,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 113.59,,CLAIM ADJUSTMENT 3, 149.90,OTHER, 108.18, 246.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44966,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 46.09,,CLAIM ADJUSTMENT 3, 167.02,OTHER, 46.09, 313.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44967,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 46.09,,CLAIM ADJUSTMENT 3, 76.10,OTHER, 46.09, 130.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44968,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 46.09,,CLAIM ADJUSTMENT 3, 147.35,OTHER, 46.09, 273.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44969,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 227.22,OTHER, 124.32, 396.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44970,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 295.49,OTHER, 124.32, 533.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44971,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 114.40,OTHER, 74.67, 170.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44972,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 124.32,,CLAIM ADJUSTMENT 3, 155.48,OTHER, 110.85, 252.63,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44973,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44974,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44975,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44976,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 114.13,,CLAIM ADJUSTMENT 3, 36.72,OTHER, 8.41, 114.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44977,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 114.13,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 114.13, 360.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44978,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 114.13,,CLAIM ADJUSTMENT 3, 207.04,OTHER, 114.13, 360.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44979,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 346.21,,CLAIM ADJUSTMENT 3, 526.62,OTHER, 346.21, 891.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44980,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 346.21,,CLAIM ADJUSTMENT 3, 290.83,OTHER, 143.52, 346.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44981,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 44982,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 49.24,,CLAIM ADJUSTMENT 3, 162.12,OTHER, 49.24, 301.84,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44983,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 80.99,,CLAIM ADJUSTMENT 3, 140.39,OTHER, 80.99, 243.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44984,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 80.99,,CLAIM ADJUSTMENT 3, 140.39,OTHER, 80.99, 243.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44985,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 51.13,,CLAIM ADJUSTMENT 3, 166.97,OTHER, 51.13, 310.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44986,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 51.13,,CLAIM ADJUSTMENT 3, 54.96,OTHER, 37.67, 85.86,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44987,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 51.13,,CLAIM ADJUSTMENT 3, 86.43,OTHER, 51.13, 149.03,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44988,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 656.16,,CLAIM ADJUSTMENT 3, 950.56,OTHER, 656.16, 1594.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44989,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 656.16,,CLAIM ADJUSTMENT 3, 375.80,OTHER, 121.44, 656.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44990,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 545.72,OTHER, 384.68, 911.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44991,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 545.72,OTHER, 384.68, 911.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44992,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 278.85,OTHER, 121.44, 384.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44993,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 384.68,,CLAIM ADJUSTMENT 3, 278.85,OTHER, 121.44, 384.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44994,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 591.97,OTHER, 225.62, 1080.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44995,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44996,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 96.59,,CLAIM ADJUSTMENT 3, 250.40,OTHER, 96.59, 456.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44997,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 96.59,,CLAIM ADJUSTMENT 3, 250.40,OTHER, 96.59, 456.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44998,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 157.67,,CLAIM ADJUSTMENT 3, 197.77,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 44999,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 563.65,OTHER, 225.62, 1023.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45000,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45001,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 113.30,OTHER, 70.09, 159.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45002,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 113.30,OTHER, 70.09, 159.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45003,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45004,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45005,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 297.88,OTHER, 215.00, 490.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45006,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45007,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 262.11,OTHER, 141.55, 458.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45008,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 262.11,OTHER, 141.55, 458.40,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45009,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45010,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45011,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 673.61,OTHER, 225.62, 1244.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45012,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 673.61,OTHER, 225.62, 1244.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45013,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 383.08,OTHER, 225.62, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45014,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 673.61,OTHER, 225.62, 1244.07,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45015,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45016,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45017,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45018,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45019,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45020,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45021,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45022,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 363.06,OTHER, 141.55, 660.99,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45023,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45024,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45025,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45026,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 141.55,,CLAIM ADJUSTMENT 3, 192.01,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45027,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 655.39,OTHER, 225.62, 1207.49,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45028,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 225.62,,CLAIM ADJUSTMENT 3, 222.04,OTHER, 121.44, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45029,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 284.89,,CLAIM ADJUSTMENT 3, 1042.14,OTHER, 284.89, 2539.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45030,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 284.89,,CLAIM ADJUSTMENT 3, 1042.14,OTHER, 284.89, 2539.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45031,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 184.77,OTHER, 39.56, 427.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45032,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 184.77,OTHER, 39.56, 427.28,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45033,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 138.71,,CLAIM ADJUSTMENT 3, 547.41,OTHER, 138.71, 1032.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45034,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 152.82,,CLAIM ADJUSTMENT 3, 154.36,OTHER, 103.88, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45035,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 152.82,,CLAIM ADJUSTMENT 3, 154.36,OTHER, 103.88, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45036,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 199.86,OTHER, 125.79, 286.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45037,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 199.86,OTHER, 125.79, 286.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45038,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 407.38,OTHER, 140.42, 864.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45039,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 407.38,OTHER, 140.42, 864.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45040,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 407.38,OTHER, 140.42, 864.36,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45041,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 140.42,,CLAIM ADJUSTMENT 3, 332.46,OTHER, 140.42, 600.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45042,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 239.03,OTHER, 160.29, 365.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45043,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 239.03,OTHER, 160.29, 365.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45044,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 239.44,,CLAIM ADJUSTMENT 3, 174.98,OTHER, 103.88, 239.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45045,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 76.16,,CLAIM ADJUSTMENT 3, 136.10,OTHER, 76.16, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45046,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 140.33,OTHER, 74.39, 234.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45047,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 87.35,,CLAIM ADJUSTMENT 3, 228.33,OTHER, 87.35, 416.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45048,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45049,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45050,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 94.34,,CLAIM ADJUSTMENT 3, 182.46,OTHER, 94.34, 321.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45051,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 94.34,,CLAIM ADJUSTMENT 3, 182.46,OTHER, 94.34, 321.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45052,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 125.89,OTHER, 61.67, 234.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45053,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 234.58,,CLAIM ADJUSTMENT 3, 125.89,OTHER, 61.67, 234.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45054,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 235.80,,CLAIM ADJUSTMENT 3, 415.63,OTHER, 235.80, 721.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45055,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 1853.96,OTHER, 1121.15, 3185.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45056,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 1853.96,OTHER, 1121.15, 3185.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45057,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 2171.37,OTHER, 1121.15, 3822.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45058,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 2171.37,OTHER, 1121.15, 3822.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45059,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1121.15,,CLAIM ADJUSTMENT 3, 2171.37,OTHER, 1121.15, 3822.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45060,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 85.61,,CLAIM ADJUSTMENT 3, 152.82,OTHER, 85.61, 265.80,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45061,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 89.47,,CLAIM ADJUSTMENT 3, 165.98,OTHER, 89.47, 290.35,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45062,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 110.12,,CLAIM ADJUSTMENT 3, 260.74,OTHER, 110.12, 470.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45063,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 110.12,,CLAIM ADJUSTMENT 3, 260.74,OTHER, 110.12, 470.66,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45064,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 96.89,OTHER, 37.34, 176.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45065,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 96.89,OTHER, 37.34, 176.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45066,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 184.46,,CLAIM ADJUSTMENT 3, 323.07,OTHER, 184.46, 560.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45067,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 184.46,,CLAIM ADJUSTMENT 3, 323.07,OTHER, 184.46, 560.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45068,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 184.46,,CLAIM ADJUSTMENT 3, 323.07,OTHER, 184.46, 560.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45069,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 89.33,OTHER, 37.34, 161.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45070,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 89.33,OTHER, 37.34, 161.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45071,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 108.89,OTHER, 54.48, 192.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45072,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 108.89,OTHER, 54.48, 192.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45073,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45074,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45075,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 84.04,OTHER, 37.34, 150.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45076,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 84.04,OTHER, 37.34, 150.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45077,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 37.95,OTHER, 25.59, 58.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45078,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 37.95,OTHER, 25.59, 58.31,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45079,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 159.88,OTHER, 54.48, 294.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45080,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 159.88,OTHER, 54.48, 294.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45081,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 96.44,OTHER, 54.48, 167.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45082,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 54.48,,CLAIM ADJUSTMENT 3, 96.44,OTHER, 54.48, 167.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45083,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45084,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45085,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 21.01,,CLAIM ADJUSTMENT 3, 47.95,OTHER, 21.01, 86.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45086,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 21.01,,CLAIM ADJUSTMENT 3, 47.95,OTHER, 21.01, 86.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45087,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 34.39,,CLAIM ADJUSTMENT 3, 55.33,OTHER, 34.39, 94.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45088,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 34.39,,CLAIM ADJUSTMENT 3, 55.33,OTHER, 34.39, 94.61,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45089,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 29.74,,CLAIM ADJUSTMENT 3, 58.74,OTHER, 29.74, 103.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45090,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 29.74,,CLAIM ADJUSTMENT 3, 58.74,OTHER, 29.74, 103.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45091,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 29.74,,CLAIM ADJUSTMENT 3, 58.74,OTHER, 29.74, 103.67,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45092,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 28.82,,CLAIM ADJUSTMENT 3, 142.33,OTHER, 28.82, 411.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45093,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 28.82,,CLAIM ADJUSTMENT 3, 142.33,OTHER, 28.82, 411.60,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45094,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 28.82,,CLAIM ADJUSTMENT 3, 72.71,OTHER, 28.82, 132.15,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45095,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 74.33,OTHER, 52.80, 120.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45096,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 74.33,OTHER, 52.80, 120.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45097,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 74.35,OTHER, 52.84, 120.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45098,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 69.01,,CLAIM ADJUSTMENT 3, 80.43,OTHER, 56.36, 128.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45099,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 69.01,,CLAIM ADJUSTMENT 3, 80.43,OTHER, 56.36, 128.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45100,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 69.01,,CLAIM ADJUSTMENT 3, 80.43,OTHER, 56.36, 128.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45101,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 60.80,OTHER, 40.91, 93.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45102,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 60.25,,CLAIM ADJUSTMENT 3, 60.80,OTHER, 40.91, 93.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45103,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 61.55,,CLAIM ADJUSTMENT 3, 47.68,OTHER, 29.08, 66.27,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45104,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 46.96,,CLAIM ADJUSTMENT 3, 98.59,OTHER, 46.96, 175.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45105,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 46.96,,CLAIM ADJUSTMENT 3, 98.59,OTHER, 46.96, 175.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45106,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 46.96,,CLAIM ADJUSTMENT 3, 98.59,OTHER, 46.96, 175.42,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45107,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 44.87,,CLAIM ADJUSTMENT 3, 115.67,OTHER, 44.87, 210.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45108,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 44.87,,CLAIM ADJUSTMENT 3, 115.67,OTHER, 44.87, 210.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45109,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 44.87,,CLAIM ADJUSTMENT 3, 115.67,OTHER, 44.87, 210.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45110,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 55.58,,CLAIM ADJUSTMENT 3, 73.14,OTHER, 52.75, 120.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45111,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 55.58,,CLAIM ADJUSTMENT 3, 73.14,OTHER, 52.75, 120.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45112,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 55.58,,CLAIM ADJUSTMENT 3, 73.14,OTHER, 52.75, 120.22,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45113,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.13,,CLAIM ADJUSTMENT 3, 30.33,OTHER, 18.92, 43.12,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45114,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 206.21,,CLAIM ADJUSTMENT 3, 178.52,OTHER, 113.97, 259.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45115,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 206.21,,CLAIM ADJUSTMENT 3, 202.67,OTHER, 135.24, 308.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45116,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 206.21,,CLAIM ADJUSTMENT 3, 194.50,OTHER, 128.04, 291.81,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45117,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 142.50,,CLAIM ADJUSTMENT 3, 106.37,OTHER, 63.79, 145.39,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45118,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 208.14,,CLAIM ADJUSTMENT 3, 173.75,OTHER, 109.36, 249.24,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45119,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 208.14,,CLAIM ADJUSTMENT 3, 180.83,OTHER, 115.60, 263.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45120,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 208.14,,CLAIM ADJUSTMENT 3, 204.49,OTHER, 136.43, 310.94,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45121,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 143.15,,CLAIM ADJUSTMENT 3, 108.91,OTHER, 65.89, 150.18,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45122,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 41.16,,CLAIM ADJUSTMENT 3, 68.75,OTHER, 41.16, 118.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45123,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 41.16,,CLAIM ADJUSTMENT 3, 68.75,OTHER, 41.16, 118.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45124,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 41.16,,CLAIM ADJUSTMENT 3, 68.75,OTHER, 41.16, 118.30,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45125,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.16,,CLAIM ADJUSTMENT 3, 44.69,OTHER, 31.56, 71.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45126,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 66.74,,CLAIM ADJUSTMENT 3, 78.22,OTHER, 54.89, 125.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45127,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 66.74,,CLAIM ADJUSTMENT 3, 78.22,OTHER, 54.89, 125.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45128,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 66.74,,CLAIM ADJUSTMENT 3, 59.17,OTHER, 38.11, 86.85,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45129,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 39.73,,CLAIM ADJUSTMENT 3, 66.10,OTHER, 39.73, 113.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45130,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 39.73,,CLAIM ADJUSTMENT 3, 66.10,OTHER, 39.73, 113.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45131,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 39.73,,CLAIM ADJUSTMENT 3, 66.10,OTHER, 39.73, 113.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45132,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 151.16,,CLAIM ADJUSTMENT 3, 68.90,OTHER, 12.81, 151.16,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45133,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 96.26,,CLAIM ADJUSTMENT 3, 93.12,OTHER, 61.82, 140.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45134,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 84.59,,CLAIM ADJUSTMENT 3, 114.40,OTHER, 52.03, 259.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45135,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 84.59,,CLAIM ADJUSTMENT 3, 114.40,OTHER, 52.03, 259.74,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45136,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 105.23,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 53.32, 121.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45137,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 105.23,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 53.32, 121.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45138,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 105.23,,CLAIM ADJUSTMENT 3, 85.61,OTHER, 53.32, 121.52,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45139,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45140,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45141,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45142,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45143,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45144,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45145,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45146,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45147,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45148,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45149,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 114.64,,CLAIM ADJUSTMENT 3, 145.27,OTHER, 103.88, 236.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45150,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45151,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45152,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45153,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45154,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45155,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45156,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45157,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45158,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45159,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45160,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45161,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45162,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45163,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45164,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45165,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45166,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45167,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45168,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45169,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 103.66,,CLAIM ADJUSTMENT 3, 111.61,OTHER, 64.03, 142.10,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45170,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 164.56,,CLAIM ADJUSTMENT 3, 149.82,OTHER, 78.16, 173.46,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45171,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 247.58,,CLAIM ADJUSTMENT 3, 220.11,OTHER, 113.05, 250.88,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45172,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 149.74,OTHER, 77.35, 263.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45173,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 149.74,OTHER, 77.35, 263.54,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45174,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 156.74,OTHER, 77.35, 245.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45175,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 77.35,,CLAIM ADJUSTMENT 3, 156.74,OTHER, 77.35, 245.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45176,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 233.57,OTHER, 127.82, 407.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45177,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 233.57,OTHER, 127.82, 407.68,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45178,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 197.91,OTHER, 127.82, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45179,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 127.82,,CLAIM ADJUSTMENT 3, 197.91,OTHER, 127.82, 290.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45180,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 369.55,OTHER, 203.96, 644.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45181,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 369.55,OTHER, 203.96, 644.19,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45182,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 247.74,OTHER, 150.14, 333.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45183,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 203.96,,CLAIM ADJUSTMENT 3, 247.74,OTHER, 150.14, 333.20,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45184,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 580.80,OTHER, 324.71, 1010.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45185,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 580.80,OTHER, 324.71, 1010.45,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45186,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 332.53,OTHER, 185.91, 412.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45187,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 324.71,,CLAIM ADJUSTMENT 3, 332.53,OTHER, 185.91, 412.58,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45188,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 479.76,,CLAIM ADJUSTMENT 3, 954.02,OTHER, 479.76, 1685.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45189,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 479.76,,CLAIM ADJUSTMENT 3, 954.02,OTHER, 479.76, 1685.38,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45190,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 479.76,,CLAIM ADJUSTMENT 3, 429.06,OTHER, 221.24, 490.98,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45191,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 720.78,,CLAIM ADJUSTMENT 3, 1514.86,OTHER, 720.78, 2695.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45192,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45193,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45194,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45195,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45196,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 167.97,OTHER, 113.31, 258.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45197,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 173.37,OTHER, 118.06, 269.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45198,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 179.18,OTHER, 123.17, 280.72,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45199,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 197.44,OTHER, 139.26, 317.37,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45200,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 192.88,OTHER, 135.24, 308.21,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45201,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45202,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45203,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 155.10,OTHER, 101.97, 232.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45204,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 162.99,OTHER, 108.92, 248.23,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45205,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 174.20,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45206,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 174.20,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45207,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 174.20,OTHER, 118.79, 270.73,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45208,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 177.10,OTHER, 121.35, 276.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45209,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45210,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45211,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45212,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45213,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45214,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45215,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 30.74,,CLAIM ADJUSTMENT 3, 33.14,OTHER, 22.74, 51.82,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45216,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 30.74,,CLAIM ADJUSTMENT 3, 39.28,OTHER, 28.14, 64.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45217,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45218,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45219,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45220,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45221,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 101.33,,CLAIM ADJUSTMENT 3, 148.65,OTHER, 101.33, 249.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45222,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 133.36,,CLAIM ADJUSTMENT 3, 166.04,OTHER, 118.25, 269.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45223,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45224,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45225,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 680.93,,CLAIM ADJUSTMENT 3, 350.13,OTHER, 165.55, 680.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45226,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 680.93,,CLAIM ADJUSTMENT 3, 350.13,OTHER, 165.55, 680.93,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45227,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1078.14,,CLAIM ADJUSTMENT 3, 553.11,OTHER, 261.01, 1078.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45228,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1078.14,,CLAIM ADJUSTMENT 3, 553.11,OTHER, 261.01, 1078.14,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45229,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 567.43,,CLAIM ADJUSTMENT 3, 308.45,OTHER, 152.65, 567.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45230,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 567.43,,CLAIM ADJUSTMENT 3, 308.45,OTHER, 152.65, 567.43,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45231,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 907.91,,CLAIM ADJUSTMENT 3, 466.19,OTHER, 220.16, 907.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45232,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 907.91,,CLAIM ADJUSTMENT 3, 466.19,OTHER, 220.16, 907.91,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45233,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45234,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45235,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45236,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45237,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45238,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45239,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45240,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1648.47,OTHER, 779.04, 2936.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45241,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1648.47,OTHER, 779.04, 2936.08,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45242,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1777.88,OTHER, 779.04, 3195.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45243,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1777.88,OTHER, 779.04, 3195.78,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45244,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1244.21,OTHER, 508.57, 2254.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45245,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1244.21,OTHER, 508.57, 2254.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45246,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1244.21,OTHER, 508.57, 2254.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45247,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1097.72,OTHER, 508.57, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45248,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 508.57,,CLAIM ADJUSTMENT 3, 1097.72,OTHER, 508.57, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45249,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1162.11,OTHER, 779.04, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45250,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 779.04,,CLAIM ADJUSTMENT 3, 1162.11,OTHER, 779.04, 1960.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45251,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1.66,,CLAIM ADJUSTMENT 3, 9.74,OTHER, 1.66, 18.76,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45252,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 63.90,OTHER, 37.34, 110.41,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45253,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 37.34,,CLAIM ADJUSTMENT 3, 11.82,OTHER, 2.58, 37.34,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45254,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45255,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45256,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 33.71,,CLAIM ADJUSTMENT 3, 88.75,OTHER, 33.71, 162.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45257,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 33.71,,CLAIM ADJUSTMENT 3, 58.81,OTHER, 33.71, 101.92,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45258,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45259,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 231.89,OTHER, 165.06, 386.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45260,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 165.06,,CLAIM ADJUSTMENT 3, 231.89,OTHER, 165.06, 386.51,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45261,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 35.44,OTHER, 18.28, 61.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45262,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 61.69,,CLAIM ADJUSTMENT 3, 44.57,OTHER, 26.32, 61.69,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45263,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45264,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45265,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45266,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45267,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45268,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45269,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45270,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45271,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45272,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45273,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45274,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45275,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45276,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45277,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45278,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45279,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45280,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45281,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45282,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45283,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45284,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45285,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45286,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45287,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1597.44,,CLAIM ADJUSTMENT 3, 575.18,OTHER, 171.57, 1597.44,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45288,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2082.47,,CLAIM ADJUSTMENT 3, 690.66,OTHER, 171.57, 2082.47,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45289,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1937.50,,CLAIM ADJUSTMENT 3, 656.15,OTHER, 171.57, 1937.50,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45290,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 1734.01,,CLAIM ADJUSTMENT 3, 607.70,OTHER, 171.57, 1734.01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45291,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 2065.06,,CLAIM ADJUSTMENT 3, 735.35,OTHER, 214.57, 2065.06,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45292,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 18.42,,CLAIM ADJUSTMENT 3, 421.89,OTHER, 18.42, 837.90,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45293,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45294,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45295,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45296,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45297,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45298,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45299,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45300,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45301,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45302,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45303,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45304,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45305,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 110.60,,CLAIM ADJUSTMENT 3, 196.27,OTHER, 110.60, 341.04,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45306,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45307,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45308,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45309,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 206.22,,CLAIM ADJUSTMENT 3, 251.75,OTHER, 178.45, 406.70,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45310,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45311,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45312,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45313,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45314,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45315,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45316,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45317,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45318,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45319,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45320,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45321,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45322,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45323,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45324,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45325,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45326,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45327,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45328,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45329,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 682.56,,CLAIM ADJUSTMENT 3, 810.02,OTHER, 570.18, 1299.48,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45330,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 42.53,,CLAIM ADJUSTMENT 3, 62.01,OTHER, 42.53, 104.13,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45331,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45332,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, 64.45,,CLAIM ADJUSTMENT 3, 64.18,OTHER, 43.00, 98.00,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45333,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45334,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45335,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45336,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45337,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45338,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45339,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45340,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45341,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45342,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45343,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45344,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45345,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45346,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45347,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45348,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45349,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45350,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45351,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45352,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45353,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45354,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45355,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45356,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45357,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45358,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45359,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45360,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45361,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45362,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45363,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45364,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45365,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45366,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45367,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45368,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45369,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45370,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45371,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45372,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45373,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45374,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45375,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45376,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45377,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45378,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45379,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45380,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45381,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45382,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45383,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45384,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45385,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45386,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45387,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45388,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45389,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45390,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45391,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45392,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45393,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45394,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45395,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45396,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45397,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45398,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45399,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45400,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, 35.99,OTHER, .01, 560.56,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45401,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45402,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45403,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45404,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45405,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45406,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45407,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45408,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45409,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45410,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45411,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45412,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45413,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45414,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45415,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45416,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45417,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45418,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45419,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45420,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45421,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45422,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45423,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45424,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45425,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45426,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45427,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45428,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45429,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45430,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45431,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45432,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45433,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45434,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45435,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45436,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45437,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45438,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45439,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45440,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45441,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45442,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45443,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45444,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45445,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45446,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45447,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45448,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45449,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45450,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45451,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45452,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45453,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45454,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45455,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45456,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45457,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45458,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45459,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45460,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45461,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45462,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID,,,,,,,,CODE COMBINATION NOT COVERED BY THIS PLAN 45463,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,WESTSKY_TURQ_MEDICAI,WESTERN SKY TURQUOISE MEDICAID, .01,,CLAIM ADJUSTMENT 3, .01,OTHER, .01, .01,OVERALL CLAIM ADJUSTMENT BASED ON DIAGNOSIS CODES - HCPCS CODES - REVENUE CODES - OR NO CODES - ADJUSTMENT CAN BE FLAT RATE OR PERCENTAGE. 45464,ROOM/BED: MED SURG,,,111,RC,8631615,CDM,,,,INPATIENT,,, 1150.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 977.50,,OUTPCT LIMIT, 920.20,OTHER, 507.84, 1127.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45465,ROOM/BED: SWING BED,,,119,RC,8085548,CDM,,,,INPATIENT,,, 850.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 722.50,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45466,ROOM/BED: TELEMETRY,,,119,RC,2120847,CDM,,,,INPATIENT,,, 1375.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1168.75,,OUTPCT LIMIT, 890.20,OTHER, 375.36, 1347.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45467,00120 PROC EXT/MID/IN EAR W/BX PROFEE,00120,HCPCS,370,RC,8016142,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45468,00300 ANES PER MINUTE PROFEE,00300,HCPCS,999,RC,8016147,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45469,00400 ANES PER MINUTE PROFEE,00400,HCPCS,999,RC,8016150,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45470,00404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES,00404,HCPCS,999,RC,8473570,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45471,00731 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,00731,HCPCS,999,RC,8473572,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45472,00750 ANES PER MINUTE PROFEE,00750,HCPCS,370,RC,8016163,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45473,00752 ANES PER MINUTE PROFEE,00752,HCPCS,370,RC,8016164,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45474,00790 ANES PER MINUTE PROFEE,00790,HCPCS,999,RC,8016165,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45475,00811 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00811,HCPCS,999,RC,8473574,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45476,00812 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,00812,HCPCS,370,RC,8473575,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45477,00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROC,00813,HCPCS,999,RC,8473576,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45478,00830 ANES PER MINUTE PROFEE,00830,HCPCS,999,RC,8016169,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45479,00832 VENTRAL INCISIONAL HERNIA PROFEE,00832,HCPCS,370,RC,8016170,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45480,00840 ANES PER MINUTE PROFEE,00840,HCPCS,999,RC,8016171,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45481,01220 ANES CLSD UPPER 2/3 FEMUR PROFEE,01220,HCPCS,999,RC,8016202,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45482,10060-IANDD ABSCESS/CYST/HEMATOMA SIMPLE,10060,HCPCS,450,RC,8102058,CDM,,,,OUTPATIENT,,, 486.80, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 413.78,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45483,10060 INCISION AND DRAINAGE ABSCESS SIMPLE/SINGLE TECHFEE,10060,HCPCS,450,RC,8022538,CDM,,,,OUTPATIENT,,, 486.80, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 413.78,,OUTPCT LIMIT, 271.70,OTHER, 142.76, 477.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45484,10060 INCISION AND DRAINAGE OF ABSCESS SIMPLE OR SINGLE,10060,HCPCS,521,RC,8036699,CDM,,,,OUTPATIENT,,, 276.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 234.81,,OUTPCT LIMIT, 168.89,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45485,10060 INCISION AND DRAINAGE OF ABSCESS (EG CARBUNCLE SUPPURATIVE HIDRADENITIS,10060,HCPCS,960,RC,8016366,CDM,,,,OUTPATIENT,,, 234.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 198.90,,OUTPCT LIMIT, 171.36,OTHER, 103.33, 229.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45486,10061 INCISION AND DRAINAGE OF ABSCESS COMPLICATED OR MULTIPLE,10061,HCPCS,521,RC,8036700,CDM,,,,OUTPATIENT,,, 491.23, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 417.55,,OUTPCT LIMIT, 273.87,OTHER, 142.76, 481.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45487,10061 IANDD ABSCESS COMPLICATED/MULTIPLE PROFEE,10061,HCPCS,999,RC,9117749,CDM,,,,OUTPATIENT,,, 439.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 373.15,,OUTPCT LIMIT, 276.81,OTHER, 142.76, 430.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45488,10120 INCISION AND REMOVAL OF FOREIGN BODY SUBCUTANEOUS TISSUES SIMPLE,10120,HCPCS,521,RC,8036703,CDM,,,,OUTPATIENT,,, 362.10, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 307.79,,OUTPCT LIMIT, 242.16,OTHER, 155.70, 354.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45489,10121 IANDR FOREIGN BODY SUBQ TISS COMPL PROFEE,10121,HCPCS,999,RC,9117751,CDM,,,,OUTPATIENT,,, 461.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 391.85,,OUTPCT LIMIT, 850.02,OTHER, 203.58, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45490,10140 INCISION AND DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION PROFEE,10140,HCPCS,999,RC,8016372,CDM,,,,OUTPATIENT,,, 439.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 373.15,,OUTPCT LIMIT, 667.92,OTHER, 193.86, 1237.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45491,11042 DEBRIDEMENT SUBCUTANEOUS TISSUE,11042,HCPCS,999,RC,8016386,CDM,,,,OUTPATIENT,,, 154.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 130.90,,OUTPCT LIMIT, 177.23,OTHER, 68.01, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45492,11045 DEBRIDEMENT SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS IF PERF),11045,HCPCS,999,RC,8016389,CDM,,,,OUTPATIENT,,, 70.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 59.50,,OUTPCT LIMIT, 131.69,OTHER, 30.91, 267.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45493,11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG CORN OR CALLUS) SI,11055,HCPCS,999,RC,8016392,CDM,,,,OUTPATIENT,,, 127.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 107.95,,OUTPCT LIMIT, 116.49,OTHER, 56.08, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45494,11102 TANGENTIAL BIOPSY SKIN SINGLE LESION PROFEE,11102,HCPCS,999,RC,8295806,CDM,,,,OUTPATIENT,,, 610.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 518.50,,OUTPCT LIMIT, 405.48,OTHER, 256.74, 597.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45495,11103 TANGENTIAL BIOPSY OF SKIN (EG SHAVE SCOOP SAUCERIZE CURETTE),11103,HCPCS,999,RC,8835882,CDM,,,,OUTPATIENT,,, 367.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 311.95,,OUTPCT LIMIT, 293.67,OTHER, 162.07, 359.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45496,11104 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) SINGLE LES,11104,HCPCS,999,RC,8836623,CDM,,,,OUTPATIENT,,, 243.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 206.55,,OUTPCT LIMIT, 216.69,OTHER, 107.31, 256.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45497,11105 PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE WHEN PERFORMED) E,11105,HCPCS,999,RC,8836624,CDM,,,,OUTPATIENT,,, 77.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 65.45,,OUTPCT LIMIT, 61.61,OTHER, 34.00, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45498,11106 INCISIONAL BIOPSY SINGLE LESION PRO FEE,11106,HCPCS,999,RC,8620628,CDM,,,,OUTPATIENT,,, 137.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 116.45,,OUTPCT LIMIT, 233.68,OTHER, 60.50, 456.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45499,11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO AND,11200,HCPCS,999,RC,8016397,CDM,,,,OUTPATIENT,,, 209.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 177.65,,OUTPCT LIMIT, 158.67,OTHER, 92.29, 204.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45500,11301 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11301,HCPCS,999,RC,8016400,CDM,,,,OUTPATIENT,,, 159.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 135.15,,OUTPCT LIMIT, 112.58,OTHER, 70.21, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45501,11302 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR,11302,HCPCS,999,RC,8016401,CDM,,,,OUTPATIENT,,, 184.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 156.40,,OUTPCT LIMIT, 125.44,OTHER, 81.25, 180.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45502,11303 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION TRUNK ARMS OR LEGS,11303,HCPCS,999,RC,8016402,CDM,,,,OUTPATIENT,,, 117.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 99.45,,OUTPCT LIMIT, 114.17,OTHER, 51.67, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45503,11305 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION SCALP NECK HANDS,11305,HCPCS,999,RC,8016403,CDM,,,,OUTPATIENT,,, 138.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 117.30,,OUTPCT LIMIT, 122.15,OTHER, 60.94, 143.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45504,11310 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS,11310,HCPCS,999,RC,8016407,CDM,,,,OUTPATIENT,,, 210.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 178.50,,OUTPCT LIMIT, 138.81,OTHER, 86.20, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45505,11311 SHAVING OF EPIDERMAL OR DERMAL LESION SINGLE LESION FACE EARS EYELIDS,11311,HCPCS,999,RC,8016408,CDM,,,,OUTPATIENT,,, 168.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 142.80,,OUTPCT LIMIT, 117.21,OTHER, 74.19, 164.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45506,11400 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11400,HCPCS,999,RC,8016411,CDM,,,,OUTPATIENT,,, 205.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 174.25,,OUTPCT LIMIT, 258.26,OTHER, 90.53, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45507,11401 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11401,HCPCS,999,RC,8016412,CDM,,,,OUTPATIENT,,, 262.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 222.70,,OUTPCT LIMIT, 287.58,OTHER, 115.70, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45508,11402 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11402,HCPCS,999,RC,8016413,CDM,,,,OUTPATIENT,,, 353.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 300.05,,OUTPCT LIMIT, 334.39,OTHER, 155.88, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45509,11403 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11403,HCPCS,999,RC,8016414,CDM,,,,OUTPATIENT,,, 2386.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2028.10,,OUTPCT LIMIT, 1514.68,OTHER, 804.50, 2338.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45510,11404 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11404,HCPCS,999,RC,8016415,CDM,,,,OUTPATIENT,,, 1348.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1145.80,,OUTPCT LIMIT, 1306.30,OTHER, 595.28, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45511,11406 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11406,HCPCS,999,RC,8016416,CDM,,,,OUTPATIENT,,, 608.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 516.80,,OUTPCT LIMIT, 925.64,OTHER, 268.49, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45512,11420 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11420,HCPCS,999,RC,8016417,CDM,,,,OUTPATIENT,,, 199.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 169.15,,OUTPCT LIMIT, 389.69,OTHER, 87.88, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45513,11421 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11421,HCPCS,999,RC,8016418,CDM,,,,OUTPATIENT,,, 272.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 231.20,,OUTPCT LIMIT, 427.24,OTHER, 120.12, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45514,11422 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11422,HCPCS,999,RC,8016419,CDM,,,,OUTPATIENT,,, 331.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 281.35,,OUTPCT LIMIT, 457.59,OTHER, 146.17, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45515,11424 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11424,HCPCS,999,RC,8016421,CDM,,,,OUTPATIENT,,, 233.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 198.05,,OUTPCT LIMIT, 732.74,OTHER, 102.89, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45516,11426 EXCISION BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11426,HCPCS,999,RC,8016422,CDM,,,,OUTPATIENT,,, 679.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 577.15,,OUTPCT LIMIT, 1168.49,OTHER, 299.85, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45517,11440 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11440,HCPCS,999,RC,8016423,CDM,,,,OUTPATIENT,,, 287.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 243.95,,OUTPCT LIMIT, 300.44,OTHER, 126.74, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45518,11442 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11442,HCPCS,999,RC,8016425,CDM,,,,OUTPATIENT,,, 404.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 343.40,,OUTPCT LIMIT, 495.14,OTHER, 178.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45519,11443 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11443,HCPCS,999,RC,8016426,CDM,,,,OUTPATIENT,,, 481.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 408.85,,OUTPCT LIMIT, 534.75,OTHER, 212.41, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45520,11444 EXCISION OTHER BENIGN LESION INCLUDING MARGINS EXCEPT SKIN TAG,11444,HCPCS,999,RC,8016427,CDM,,,,OUTPATIENT,,, 555.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 471.75,,OUTPCT LIMIT, 572.81,OTHER, 245.09, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45521,11603 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS,11603,HCPCS,999,RC,8016438,CDM,,,,OUTPATIENT,,, 495.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 420.75,,OUTPCT LIMIT, 541.95,OTHER, 218.59, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45522,11604 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11604,HCPCS,999,RC,8016439,CDM,,,,OUTPATIENT,,, 567.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 481.95,,OUTPCT LIMIT, 578.99,OTHER, 250.39, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45523,11606 EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARMS OR LEGS EXCISED,11606,HCPCS,999,RC,8016440,CDM,,,,OUTPATIENT,,, 1736.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1475.60,,OUTPCT LIMIT, 1505.88,OTHER, 766.62, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45524,11622 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11622,HCPCS,999,RC,8016443,CDM,,,,OUTPATIENT,,, 699.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 594.15,,OUTPCT LIMIT, 646.89,OTHER, 308.68, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45525,11626 EXCISION MALIGNANT LESION INCLUDING MARGINS SCALP NECK HANDS FEET,11626,HCPCS,999,RC,8016446,CDM,,,,OUTPATIENT,,, 823.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 699.55,,OUTPCT LIMIT, 1242.56,OTHER, 363.44, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45526,11641 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS,11641,HCPCS,999,RC,8016448,CDM,,,,OUTPATIENT,,, 439.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 373.15,,OUTPCT LIMIT, 513.14,OTHER, 193.86, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45527,11642 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11642,HCPCS,999,RC,8016449,CDM,,,,OUTPATIENT,,, 454.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 385.90,,OUTPCT LIMIT, 520.86,OTHER, 200.49, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45528,11643 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE,11643,HCPCS,999,RC,8016450,CDM,,,,OUTPATIENT,,, 792.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 673.20,,OUTPCT LIMIT, 694.73,OTHER, 349.75, 804.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45529,11644 EXCISION MALIGNANT LESION INCLUDING MARGINS,11644,HCPCS,999,RC,8016451,CDM,,,,OUTPATIENT,,, 651.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 553.35,,OUTPCT LIMIT, 947.76,OTHER, 287.48, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45530,11646 EXCISION MALIGNANT LESION INCLUDING MARGINS FACE EARS EYELIDS NOSE LIPS,11646,HCPCS,999,RC,8016452,CDM,,,,OUTPATIENT,,, 1116.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 948.60,,OUTPCT LIMIT, 1393.28,OTHER, 492.83, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45531,11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) 6 OR MORE PROFEE,11721,HCPCS,999,RC,8016455,CDM,,,,OUTPATIENT,,, 56.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 47.60,,OUTPCT LIMIT, 56.01,OTHER, 24.73, 76.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45532,11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TECHFEE,11730,HCPCS,450,RC,8022610,CDM,,,,OUTPATIENT,,, 337.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 287.22,,OUTPCT LIMIT, 185.53,OTHER, 86.20, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45533,11730-AVULSION NAIL PLATE SINGLE,11730,HCPCS,960,RC,8102354,CDM,,,,OUTPATIENT,,, 129.28, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 109.89,,OUTPCT LIMIT, 97.29,OTHER, 57.09, 126.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45534,11730 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE SINGLE PROFEE,11730,HCPCS,999,RC,8016456,CDM,,,,OUTPATIENT,,, 129.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 109.65,,OUTPCT LIMIT, 97.14,OTHER, 56.97, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45535,11732 AVULSION OF NAIL PLATE PARTIAL OR COMPLETE SIMPLE EACH ADDITIONAL NAIL,11732,HCPCS,999,RC,8016457,CDM,,,,OUTPATIENT,,, 51.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 43.35,,OUTPCT LIMIT, 57.02,OTHER, 22.52, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45536,11750 EXCISION OF NAIL AND NAIL MATRIX PARTIAL OR COMPLETE,11750,HCPCS,999,RC,8016459,CDM,,,,OUTPATIENT,,, 428.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 363.80,,OUTPCT LIMIT, 372.97,OTHER, 189.00, 427.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45537,11771 EXCISION OF PILONIDAL CYST OR SINUS EXTENSIVE PROFEE,11771,HCPCS,999,RC,8016466,CDM,,,,OUTPATIENT,,, 1220.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1037.00,,OUTPCT LIMIT, 1446.78,OTHER, 538.75, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45538,11772 EXCISION OF PILONIDAL CYST OR SINUS COMPLICATED PROFEE,11772,HCPCS,999,RC,8016467,CDM,,,,OUTPATIENT,,, 588.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 499.80,,OUTPCT LIMIT, 1121.68,OTHER, 259.66, 2293.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45539,11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,11982,HCPCS,521,RC,8036810,CDM,,,,OUTPATIENT,,, 383.74, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 326.18,,OUTPCT LIMIT, 278.63,OTHER, 165.01, 383.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45540,11983 REMOVAL W/RE-INSERTION NON-BIODEGRADABLE IMPLANT,11983,HCPCS,521,RC,9467278,CDM,,,,OUTPATIENT,,, 688.84, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 585.51,,OUTPCT LIMIT, 427.61,OTHER, 296.20, 675.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45541,12001-SCALP/NECK/TRUNK/GENITAL/EXTREMITY <= 2.5 CM,12001,HCPCS,450,RC,8101958,CDM,,,,OUTPATIENT,,, 416.85, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 354.32,,OUTPCT LIMIT, 237.66,OTHER, 143.26, 408.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45542,12002-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 2.6-7.5 CM,12002,HCPCS,450,RC,8101960,CDM,,,,OUTPATIENT,,, 449.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 382.16,,OUTPCT LIMIT, 253.66,OTHER, 143.26, 440.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45543,12004-SCALP/NECK/TRUNK/GENITAL/EXTREMITY 7.6-12.5 CM,12004,HCPCS,450,RC,8101962,CDM,,,,OUTPATIENT,,, 487.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 414.38,,OUTPCT LIMIT, 272.17,OTHER, 143.26, 477.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45544,12011-FACE/EAR/EYELID/NOSE/LIP LESS THAN/EQUAL TO 2.5 CM,12011,HCPCS,450,RC,8101970,CDM,,,,OUTPATIENT,,, 444.97, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 378.22,,OUTPCT LIMIT, 251.39,OTHER, 143.26, 436.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45545,12011SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIPS,12011,HCPCS,999,RC,8016493,CDM,,,,OUTPATIENT,,, 409.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 347.65,,OUTPCT LIMIT, 261.55,OTHER, 143.26, 400.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45546,12013-FACE/EAR/EYELID/NOSE/LIP 2.6-5.0 CM,12013,HCPCS,450,RC,8101972,CDM,,,,OUTPATIENT,,, 471.92, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 401.13,,OUTPCT LIMIT, 264.56,OTHER, 143.26, 462.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45547,12032-SCALP/TRUNK/EXTREMITY 2.6-7.5CM,12032,HCPCS,450,RC,8101988,CDM,,,,OUTPATIENT,,, 476.70, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 405.20,,OUTPCT LIMIT, 306.35,OTHER, 204.98, 467.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45548,12037 REPAIR INTERMEDIATE WOUNDS OF SCALP AXILLAE TRUNK AND/OR EXTREMITIES,12037,HCPCS,999,RC,8016507,CDM,,,,OUTPATIENT,,, 851.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 723.35,,OUTPCT LIMIT, 548.12,OTHER, 309.01, 833.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45549,12042 REPAIR INTERMEDIATE WOUNDS OF NECK HANDS FEET AND/OR EXTERNAL,12042,HCPCS,999,RC,8016509,CDM,,,,OUTPATIENT,,, 492.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 418.20,,OUTPCT LIMIT, 300.52,OTHER, 132.82, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45550,12044-NECK/HAND/FEET/GENITAL 7.6-12.5 CM,12044,HCPCS,450,RC,8102002,CDM,,,,OUTPATIENT,,, 535.43, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 455.12,,OUTPCT LIMIT, 293.08,OTHER, 132.82, 524.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45551,13121-SCALP/ARMS/LEGS 2.6-7.5 CM,13121,HCPCS,450,RC,8102032,CDM,,,,OUTPATIENT,,, 1945.86, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1653.98,,OUTPCT LIMIT, 1023.77,OTHER, 309.01, 1906.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45552,13121 REPAIR COMPLEX SCALP ARMS AND/OR LEGS 2.6 CM TO 7.5 CM PROFEE,13121,HCPCS,999,RC,8016525,CDM,,,,OUTPATIENT,,, 754.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 640.90,,OUTPCT LIMIT, 498.22,OTHER, 309.01, 738.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45553,13132-FACE/NECK/HAND/FEET/GENITAL 2.6-7.5 CM,13132,HCPCS,450,RC,8102038,CDM,,,,OUTPATIENT,,, 3276.26, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2784.82,,OUTPCT LIMIT, 1703.49,OTHER, 435.32, 3210.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45554,13152 REPAIR COMPLEX EYELIDS NOSE EARS AND/OR LIPS 2.6 CM TO 7.5 CM PROFEE,13152,HCPCS,999,RC,8016532,CDM,,,,OUTPATIENT,,, 867.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 736.95,,OUTPCT LIMIT, 601.46,OTHER, 382.87, 849.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45555,13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE EXTENSIVE OR,13160,HCPCS,999,RC,8016534,CDM,,,,OUTPATIENT,,, 2703.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2297.55,,OUTPCT LIMIT, 2228.68,OTHER, 1193.64, 2648.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45556,15830 EXCISION EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE,15830,HCPCS,999,RC,8016632,CDM,,,,OUTPATIENT,,, 2936.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2495.60,,OUTPCT LIMIT, 2329.49,OTHER, 1296.54, 2877.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45557,15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL) OTHER SURGEON,15851,HCPCS,999,RC,8016647,CDM,,,,OUTPATIENT,,, 128.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 108.80,,OUTPCT LIMIT, 163.86,OTHER, 56.52, 274.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45558,16020-BURN DRESSINGS/DEBRIDEMENT SMALL,16020,HCPCS,450,RC,8102368,CDM,,,,OUTPATIENT,,, 337.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 287.22,,OUTPCT LIMIT, 200.99,OTHER, 145.30, 331.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45559,17000 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY S,17000,HCPCS,999,RC,8016681,CDM,,,,OUTPATIENT,,, 121.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 102.85,,OUTPCT LIMIT, 93.03,OTHER, 53.43, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45560,17003 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17003,HCPCS,999,RC,8016682,CDM,,,,OUTPATIENT,,, 13.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 11.05,,OUTPCT LIMIT, 22.22,OTHER, 5.74, 43.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45561,17111 DESTRUCTION (EG LASER SURGERY ELECTROSURGERY CRYOSURGERY CHEMOSURGERY,17111,HCPCS,999,RC,8016688,CDM,,,,OUTPATIENT,,, 332.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 282.20,,OUTPCT LIMIT, 224.77,OTHER, 146.61, 325.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45562,19100 BIOPSY OF BREAST PERCUTANEOUS NEEDLE CORE NOT USING IMAGING GUIDANCE,19100,HCPCS,999,RC,8016727,CDM,,,,OUTPATIENT,,, 176.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 149.60,,OUTPCT LIMIT, 251.63,OTHER, 77.72, 451.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45563,19101 BIOPSY OF BREAST OPEN INCISIONAL PROFEE,19101,HCPCS,999,RC,8016728,CDM,,,,OUTPATIENT,,, 547.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 464.95,,OUTPCT LIMIT, 1148.36,OTHER, 241.56, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45564,19120 EXCISION OF CYST FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR,19120,HCPCS,999,RC,8016733,CDM,,,,OUTPATIENT,,, 1297.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1102.45,,OUTPCT LIMIT, 1534.16,OTHER, 572.76, 2427.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45565,20526 INJECTION THERAPEUTIC (EG LOCAL ANESTHETIC CORTICOSTEROID) CARPAL,20526,HCPCS,999,RC,8016804,CDM,,,,OUTPATIENT,,, 277.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 235.45,,OUTPCT LIMIT, 232.01,OTHER, 122.32, 271.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45566,20552 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 1 OR 2 MUSCLE(S),20552,HCPCS,521,RC,8037032,CDM,,,,OUTPATIENT,,, 132.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 112.71,,OUTPCT LIMIT, 124.43,OTHER, 57.02, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45567,20553 INJECTION(S) SINGLE OR MULTIPLE TRIGGER POINT(S) 3 OR MORE MUSCLE(S),20553,HCPCS,521,RC,8037033,CDM,,,,OUTPATIENT,,, 124.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 105.40,,OUTPCT LIMIT, 120.23,OTHER, 53.32, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45568,20610-MAJOR JOINT ASPIRATE/INJECT W/O US,20610,HCPCS,521,RC,8102386,CDM,,,,OUTPATIENT,,, 144.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 122.83,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45569,20610 ARTHROCENTESIS ASPIRATION AND/OR INJECTION MAJOR JOINT OR BURSA WITHOUT,20610,HCPCS,521,RC,8037036,CDM,,,,OUTPATIENT,,, 144.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 122.83,,OUTPCT LIMIT, 130.25,OTHER, 62.14, 250.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45570,21558 RADICAL RESECTION OF TUMOR (EG SARCOMA) SOFT TISSUE OF NECK OR ANTERIOR,21558,HCPCS,999,RC,8017043,CDM,,,,OUTPATIENT,,, 8526.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 7247.10,,OUTPCT LIMIT, 5204.99,OTHER, 2293.79, 8355.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45571,21930 EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK SUBCUTANEOUS LESS,21930,HCPCS,999,RC,8017070,CDM,,,,OUTPATIENT,,, 622.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 528.70,,OUTPCT LIMIT, 932.84,OTHER, 274.68, 1716.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45572,24500 - HUMERAL SHAFT FRACTURE W/O MANIPULATION,24500,HCPCS,450,RC,8581374,CDM,,,,OUTPATIENT,,, 790.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 671.67,,OUTPCT LIMIT, 424.57,OTHER, 162.56, 774.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45573,25500-RADIAL SHAFT W/O MANIPULATION,25500,HCPCS,450,RC,8102188,CDM,,,,OUTPATIENT,,, 606.55, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 515.57,,OUTPCT LIMIT, 334.89,OTHER, 162.56, 594.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45574,25565-RADIALANDULNAR SHAFT W/ MANIPULATION,25565,HCPCS,450,RC,8102196,CDM,,,,OUTPATIENT,,, 1154.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 981.61,,OUTPCT LIMIT, 675.88,OTHER, 470.23, 1131.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45575,27788-DISTAL FIBULAR W/ MANIPULATION,27788,HCPCS,450,RC,8102226,CDM,,,,OUTPATIENT,,, 944.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 802.57,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45576,27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ TECHFEE,27788,HCPCS,450,RC,8023206,CDM,,,,OUTPATIENT,,, 944.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 802.57,,OUTPCT LIMIT, 499.77,OTHER, 162.56, 925.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45577,28515-PHALANX W/ MANIPULATION NOT GREAT TOE,28515,HCPCS,450,RC,8102242,CDM,,,,OUTPATIENT,,, 346.05, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 294.14,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45578,28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TECHFEE,28515,HCPCS,450,RC,8023310,CDM,,,,OUTPATIENT,,, 346.05, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 294.14,,OUTPCT LIMIT, 207.69,OTHER, 148.80, 339.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45579,29580 STRAPPING UNNA BOOT,29580,HCPCS,761,RC,8038096,CDM,,,,OUTPATIENT,,, 311.47, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 264.75,,OUTPCT LIMIT, 176.70,OTHER, 103.34, 305.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45580,31500 INTUBATION/ET TUBE INSERT TECHFEE,31500,HCPCS,450,RC,8042475,CDM,,,,OUTPATIENT,,, 1129.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 960.46,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45581,31500-ENDOTRACHEAL INTUBATION,31500,HCPCS,450,RC,8102314,CDM,,,,OUTPATIENT,,, 1129.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 960.46,,OUTPCT LIMIT, 596.69,OTHER, 188.66, 1107.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45582,32551-INSERTION CHEST TUBE,32551,HCPCS,450,RC,8102316,CDM,,,,OUTPATIENT,,, 1965.94, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1671.05,,OUTPCT LIMIT, 1089.64,OTHER, 544.52, 1926.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45583,BLOOD ALCOHOL DRAW,36000,HCPCS,300,RC,9060471,CDM,,,,OUTPATIENT,,, 35.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 29.75,,OUTPCT LIMIT, 22.43,OTHER, 15.05, 34.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45584,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,1779389,CDM,,,,OUTPATIENT,,, 31.05, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 26.39,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45585,VENIPUNCTURE ONLY,36415,HCPCS,300,RC,8078264,CDM,,,,OUTPATIENT,,, 31.05, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 26.39,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45586,COLLECTION BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9233501,CDM,,,,OUTPATIENT,,, 31.05, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 26.39,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45587,COLLECTION OF BLOOD BY VENIPUNCTURE,36415,HCPCS,300,RC,9365178,CDM,,,,OUTPATIENT,,, 31.05, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 26.39,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45588,COLLECTION: VENOUS DRAW,36415,HCPCS,300,RC,9244464,CDM,,,,OUTPATIENT,,, 31.05, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 26.39,,OUTPCT LIMIT, 18.10,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45589,VIST VENIPUNCTURE,36415,HCPCS,999,RC,9643956,CDM,,,,OUTPATIENT,,, 31.05, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 26.39,,OUTPCT LIMIT, 20.38,OTHER, 12.34, 30.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45590,BILL ONLY PKU SAMPLE HANDLING,36416,HCPCS,300,RC,9632211,CDM,,,,OUTPATIENT,,, 25.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 21.25,,OUTPCT LIMIT, 16.02,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45591,36430 BLOOD TRANSFUSION,36430,HCPCS,391,RC,9141513,CDM,,,,OUTPATIENT,,, 1024.11, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 870.49,,OUTPCT LIMIT, 579.04,OTHER, 331.58, 1003.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45592,36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 5,36556,HCPCS,999,RC,8019317,CDM,,,,OUTPATIENT,,, 2206.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1875.10,,OUTPCT LIMIT, 1525.88,OTHER, 974.17, 2161.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45593,36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER WITHOUT,36558,HCPCS,999,RC,8019319,CDM,,,,OUTPATIENT,,, 6240.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 5304.00,,OUTPCT LIMIT, 4097.24,OTHER, 2484.68, 6115.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45594,36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE,36561,HCPCS,999,RC,8019321,CDM,,,,OUTPATIENT,,, 6637.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 5641.45,,OUTPCT LIMIT, 4480.28,OTHER, 2930.90, 6504.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45595,36569 INSERTION OF PICC W/O SUBQ W/O IMAGE GUIDANCE 5+ PROFEE,36569,HCPCS,999,RC,8019326,CDM,,,,OUTPATIENT,,, 821.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 697.85,,OUTPCT LIMIT, 813.44,OTHER, 362.55, 1095.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45596,36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP,36576,HCPCS,999,RC,8019330,CDM,,,,OUTPATIENT,,, 7192.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 6113.20,,OUTPCT LIMIT, 4090.68,OTHER, 1095.12, 7048.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45597,BLOOD GAS DRAW TYPE -> ARTERIAL,36600,HCPCS,410,RC,9641334,CDM,,,,OUTPATIENT,,, 241.59, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 205.35,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45598,BLOOD GAS ARTERIAL RT,36600,HCPCS,410,RC,8107909,CDM,,,,OUTPATIENT,,, 241.59, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 205.35,,OUTPCT LIMIT, 124.21,OTHER, 26.22, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45599,38500 BIOPSY OR EXCISION OF LYMPH NODE(S) OPEN SUPERFICIAL PROFEE,38500,HCPCS,999,RC,8019496,CDM,,,,OUTPATIENT,,, 632.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 537.20,,OUTPCT LIMIT, 1187.28,OTHER, 279.09, 2414.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45600,40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA VESTIBULE OF MOUTH WITHOUT,40810,HCPCS,999,RC,8019565,CDM,,,,OUTPATIENT,,, 391.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 332.35,,OUTPCT LIMIT, 803.17,OTHER, 172.67, 1685.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45601,41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS CYST OR HEMATOMA OF TONGUE,41008,HCPCS,999,RC,8019584,CDM,,,,OUTPATIENT,,, 2199.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1869.15,,OUTPCT LIMIT, 1733.21,OTHER, 971.08, 2155.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45602,43200 ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING COL,43200,HCPCS,999,RC,8019753,CDM,,,,OUTPATIENT,,, 2822.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2398.70,,OUTPCT LIMIT, 1757.99,OTHER, 857.80, 2765.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45603,43235 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC INCLUDING,43235,HCPCS,999,RC,8019775,CDM,,,,OUTPATIENT,,, 333.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 283.05,,OUTPCT LIMIT, 477.65,OTHER, 147.05, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45604,43239 EGD FLEXIBLE TRANSORAL WITH BIOPSY SINGLE OR MULTIPLE PROFEE,43239,HCPCS,999,RC,8019779,CDM,,,,OUTPATIENT,,, 372.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 316.20,,OUTPCT LIMIT, 497.71,OTHER, 164.28, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45605,43245 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DILATION OF GASTRIC,43245,HCPCS,999,RC,8019785,CDM,,,,OUTPATIENT,,, 2349.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1996.65,,OUTPCT LIMIT, 1514.68,OTHER, 857.80, 2302.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45606,43246 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH DIRECTED PLACEMENT OF,43246,HCPCS,999,RC,8019786,CDM,,,,OUTPATIENT,,, 3319.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2821.15,,OUTPCT LIMIT, 2013.65,OTHER, 857.80, 3252.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45607,43247 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL,43247,HCPCS,999,RC,8019787,CDM,,,,OUTPATIENT,,, 473.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 402.05,,OUTPCT LIMIT, 549.67,OTHER, 208.88, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45608,43251 ESOPHAGOGASTRODUODENOSCOPY FLEXIBLE TRANSORAL WITH REMOVAL OF TUMOR,43251,HCPCS,999,RC,8019791,CDM,,,,OUTPATIENT,,, 529.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 449.65,,OUTPCT LIMIT, 578.48,OTHER, 233.61, 857.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45609,44120 ENTERECTOMY RESECTION OF SMALL INTESTINE SINGLE RESECTION AND ANASTO,44120,HCPCS,999,RC,8019936,CDM,,,,OUTPATIENT,,, 2756.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2342.60,,OUTPCT LIMIT, 2205.29,OTHER, 1217.05, 2700.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45610,44140 COLECTOMY PARTIAL WITH ANASTOMOSIS PROFEE,44140,HCPCS,999,RC,8019949,CDM,,,,OUTPATIENT,,, 3375.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2868.75,,OUTPCT LIMIT, 2700.60,OTHER, 1490.40, 3307.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45611,44500 GASTRO TUBE INSERT TECHFEE,44500,HCPCS,450,RC,8727437,CDM,,,,OUTPATIENT,,, 1166.23, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 991.30,,OUTPCT LIMIT, 718.33,OTHER, 501.48, 1142.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45612,44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER DIVERTICULUM,44604,HCPCS,999,RC,8020030,CDM,,,,OUTPATIENT,,, 3046.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2589.10,,OUTPCT LIMIT, 2437.34,OTHER, 1345.11, 2985.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45613,44950 APPENDECTOMY PROFEE,44950,HCPCS,999,RC,8020054,CDM,,,,OUTPATIENT,,, 1611.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1369.35,,OUTPCT LIMIT, 1780.93,OTHER, 711.42, 2666.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45614,44970 LAPAROSCOPY SURGICAL APPENDECTOMY PROFEE,44970,HCPCS,999,RC,8020057,CDM,,,,OUTPATIENT,,, 1499.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1274.15,,OUTPCT LIMIT, 2411.76,OTHER, 661.96, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45615,45330 SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45330,HCPCS,999,RC,8020095,CDM,,,,OUTPATIENT,,, 158.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 134.30,,OUTPCT LIMIT, 283.55,OTHER, 69.77, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45616,45331 SIGMOIDOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45331,HCPCS,999,RC,8020096,CDM,,,,OUTPATIENT,,, 188.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 159.80,,OUTPCT LIMIT, 298.98,OTHER, 83.02, 566.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45617,45333 SIGMOIDOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER LES,45333,HCPCS,999,RC,8020098,CDM,,,,OUTPATIENT,,, 309.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 262.65,,OUTPCT LIMIT, 482.77,OTHER, 136.45, 906.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45618,45378 COLONOSCOPY FLEXIBLE DIAGNOSTIC INCLUDING COLLECTION OF SPECIMEN,45378,HCPCS,999,RC,8020112,CDM,,,,OUTPATIENT,,, 554.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 470.90,,OUTPCT LIMIT, 603.90,OTHER, 244.65, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45619,45380 COLONOSCOPY FLEXIBLE WITH BIOPSY SINGLE OR MULTIPLE PROFEE,45380,HCPCS,999,RC,8020114,CDM,,,,OUTPATIENT,,, 649.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 551.65,,OUTPCT LIMIT, 652.77,OTHER, 286.60, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45620,45384 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S),45384,HCPCS,999,RC,8020118,CDM,,,,OUTPATIENT,,, 846.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 719.10,,OUTPCT LIMIT, 754.11,OTHER, 373.59, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45621,45385 COLONOSCOPY FLEXIBLE WITH REMOVAL OF TUMOR(S) POLYP(S) OR OTHER L,45385,HCPCS,999,RC,8020119,CDM,,,,OUTPATIENT,,, 772.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 656.20,,OUTPCT LIMIT, 716.04,OTHER, 340.92, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45622,45386 COLONOSCOPY FLEXIBLE WITH TRANSENDOSCOPIC BALLOON DILATION PROFEE,45386,HCPCS,999,RC,8020120,CDM,,,,OUTPATIENT,,, 744.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 632.40,,OUTPCT LIMIT, 701.64,OTHER, 328.55, 892.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45623,45398 COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) (EG HEMORRHOIDS) PROFEE,45398,HCPCS,999,RC,8020129,CDM,,,,OUTPATIENT,,, 3803.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3232.55,,OUTPCT LIMIT, 2366.55,OTHER, 1148.80, 3726.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45624,46050 INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL PROFEE,46050,HCPCS,999,RC,8020157,CDM,,,,OUTPATIENT,,, 251.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 213.35,,OUTPCT LIMIT, 623.49,OTHER, 110.84, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45625,46083 INCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46083,HCPCS,999,RC,8020161,CDM,,,,OUTPATIENT,,, 361.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 306.85,,OUTPCT LIMIT, 256.43,OTHER, 159.42, 353.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45626,46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG ANUS PROFEE,46220,HCPCS,999,RC,8020163,CDM,,,,OUTPATIENT,,, 278.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 236.30,,OUTPCT LIMIT, 637.38,OTHER, 122.76, 1384.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45627,46320 EXCISION OF THROMBOSED HEMORRHOID EXTERNAL PROFEE,46320,HCPCS,999,RC,8020178,CDM,,,,OUTPATIENT,,, 278.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 236.30,,OUTPCT LIMIT, 982.61,OTHER, 122.76, 2350.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45628,46922 DESTRUCTION OF LESION(S) ANUS (EG CONDYLOMA PAPILLOMA MOLLUSCUM CONT,46922,HCPCS,999,RC,8020218,CDM,,,,OUTPATIENT,,, 1482.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1259.70,,OUTPCT LIMIT, 1507.20,OTHER, 654.45, 2085.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45629,HEMORRHOIDECTOMY,46948,HCPCS,999,RC,7633740,CDM,,,,OUTPATIENT,,, 3743.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3181.55,,OUTPCT LIMIT, 3143.54,OTHER, 1652.91, 3668.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45630,47562 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY PROFEE,47562,HCPCS,999,RC,8020287,CDM,,,,OUTPATIENT,,, 1644.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1397.40,,OUTPCT LIMIT, 2486.35,OTHER, 725.99, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45631,47563 LAPAROSCOPY SURGICAL CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY PROFEE,47563,HCPCS,999,RC,8020288,CDM,,,,OUTPATIENT,,, 1787.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1518.95,,OUTPCT LIMIT, 2559.90,OTHER, 789.14, 4593.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45632,47600 CHOLECYSTECTOMY PROFEE,47600,HCPCS,999,RC,8020292,CDM,,,,OUTPATIENT,,, 1781.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1513.85,,OUTPCT LIMIT, 1425.12,OTHER, 786.49, 1745.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45633,49082 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING,49082,HCPCS,999,RC,8020355,CDM,,,,OUTPATIENT,,, 2866.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2436.10,,OUTPCT LIMIT, 1667.02,OTHER, 539.71, 2808.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45634,HERNIORRHAPHY INGUINAL W/ MESH,49505,HCPCS,999,RC,8138810,CDM,,,,OUTPATIENT,,, 1296.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1101.60,,OUTPCT LIMIT, 1786.42,OTHER, 572.31, 3135.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45635,49591 REPAIR ANTERIOR ABD HERNIA LESS THAN 3 CM,49591,HCPCS,999,RC,9040323,CDM,,,,OUTPATIENT,,, 3542.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3010.70,,OUTPCT LIMIT, 3662.54,OTHER, 1564.15, 5153.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45636,51102 ASPIRATION OF BLADDER WITH INSERTION OF SUPRAPUBIC CATHETER PROFEE,51102,HCPCS,999,RC,8020606,CDM,,,,OUTPATIENT,,, 366.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 311.10,,OUTPCT LIMIT, 889.66,OTHER, 161.63, 1963.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45637,51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG STRAIGHT,51701,HCPCS,450,RC,8020627,CDM,,,,OUTPATIENT,,, 402.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 342.51,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45638,51702 INSERTION OF TEMP INDWELLING BLADDER CATH CHARGE,51702,HCPCS,260,RC,8164906,CDM,,,,OUTPATIENT,,, 402.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 342.51,,OUTPCT LIMIT, 242.39,OTHER, 173.27, 394.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45639,54060 DESTRUCTION OF LESION(S) PENIS (EG CONDYLOMA PAPILLOMA MOLLUSCUM,54060,HCPCS,999,RC,8020789,CDM,,,,OUTPATIENT,,, 2724.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2315.40,,OUTPCT LIMIT, 2146.09,OTHER, 1202.92, 2669.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45640,58300 INSERTION OF INTRAUTERINE DEVICE (IUD),58300,HCPCS,521,RC,8039567,CDM,,,,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 199.77,OTHER, 96.75, 377.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45641,58301 REMOVAL OF INTRAUTERINE DEVICE (IUD),58301,HCPCS,521,RC,8039568,CDM,,,,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 266.50,OTHER, 96.75, 657.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45642,59409 VAGINAL DELIVERY ONLY TECHFEE,59409,HCPCS,450,RC,8023419,CDM,,,,OUTPATIENT,,, 3438.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2922.30,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45643,59409-VAGINAL DELIVERY ONLY,59409,HCPCS,450,RC,8102452,CDM,,,,OUTPATIENT,,, 3438.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2922.30,,OUTPCT LIMIT, 2146.91,OTHER, 1478.34, 3369.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45644,59425 ANTEPARTUM CARE ONLY 4-6 VISITS,59425,HCPCS,521,RC,8039653,CDM,,,,OUTPATIENT,,, 1122.85, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 954.42,,OUTPCT LIMIT, 719.65,OTHER, 482.83, 1100.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45645,59426 ANTEPARTUM CARE ONLY 7 OR MORE VISITS,59426,HCPCS,521,RC,8039654,CDM,,,,OUTPATIENT,,, 2008.55, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1707.27,,OUTPCT LIMIT, 1287.31,OTHER, 863.68, 1968.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45646,59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE),59430,HCPCS,521,RC,8039655,CDM,,,,OUTPATIENT,,, 453.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 385.82,,OUTPCT LIMIT, 290.91,OTHER, 195.18, 444.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45647,60200 EXCISION OF CYST OR ADENOMA OF THYROID OR TRANSECTION OF ISTHMUS PROFEE,60200,HCPCS,999,RC,8021219,CDM,,,,OUTPATIENT,,, 1694.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1439.90,,OUTPCT LIMIT, 2579.17,OTHER, 748.07, 4781.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45648,65205-CONJUCTIVAL SUPERFICIAL,65205,HCPCS,450,RC,8102278,CDM,,,,OUTPATIENT,,, 261.12, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 221.95,,OUTPCT LIMIT, 162.43,OTHER, 112.28, 255.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45649,65222-CORNEAL W/ SLIT LAMP,65222,HCPCS,450,RC,8102282,CDM,,,,OUTPATIENT,,, 226.08, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 192.17,,OUTPCT LIMIT, 145.32,OTHER, 97.21, 221.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45650,69200 PF REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL WITHOUT GENERAL,69200,HCPCS,521,RC,8040123,CDM,,,,OUTPATIENT,,, 144.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 122.74,,OUTPCT LIMIT, 116.13,OTHER, 62.09, 191.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45651,69210 REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION UNILATERAL,69210,HCPCS,521,RC,8040126,CDM,,,,OUTPATIENT,,, 119.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 101.15,,OUTPCT LIMIT, 76.24,OTHER, 51.17, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45652,XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,320,RC,1170203,CDM,,,TC,OUTPATIENT,,, 213.06, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 181.10,,OUTPCT LIMIT, 124.60,OTHER, 86.34, 208.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45653,REPORT XR FOREIGN BODY LOCALIZATION EYE,70030,HCPCS,999,RC,630512,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45654,XR MANDIBLE LESS THAN 4 VIEWS,70100,HCPCS,320,RC,1170303,CDM,,,TC,OUTPATIENT,,, 86.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.10,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45655,XR MANDIBLE LESS THAN 4 VIEWS - REPORT,70100,HCPCS,999,RC,630338,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45656,XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,320,RC,1170301,CDM,,,TC,OUTPATIENT,,, 137.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 116.45,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45657,REPORT XR MANDIBLE COMPLETE 4+ VIEWS,70110,HCPCS,999,RC,630340,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45658,XR MASTOIDS COMPLETE,70130,HCPCS,320,RC,1170315,CDM,,,TC,OUTPATIENT,,, 263.26, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 223.77,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45659,XR MASTOIDS COMPLETE - REPORT,70130,HCPCS,999,RC,630324,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45660,XR FACIAL BONES < 3 VIEWS,70140,HCPCS,320,RC,1170139,CDM,,,TC,OUTPATIENT,,, 86.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.10,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45661,XR FACIAL BONES < 3 VIEWS - REPORT,70140,HCPCS,999,RC,630668,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45662,XR FACIAL BONES 3+ VIEWS,70150,HCPCS,320,RC,1170141,CDM,,,TC,OUTPATIENT,,, 284.77, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 242.05,,OUTPCT LIMIT, 171.96,OTHER, 122.45, 279.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45663,REPORT XR FACIAL BONES 3+ VIEWS,70150,HCPCS,999,RC,630664,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45664,XR NASAL BONES 3+ VIEWS,70160,HCPCS,320,RC,1170329,CDM,,,TC,OUTPATIENT,,, 219.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 186.58,,OUTPCT LIMIT, 127.74,OTHER, 86.34, 215.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45665,REPORT XR NASAL BONES 3+ VIEWS,70160,HCPCS,999,RC,630310,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45666,XR ORBITS COMPLETE,70200,HCPCS,320,RC,1170339,CDM,,,TC,OUTPATIENT,,, 320.86, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 272.73,,OUTPCT LIMIT, 189.58,OTHER, 137.97, 314.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45667,REPORT XR ORBITS COMPLETE,70200,HCPCS,999,RC,630300,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45668,XR SINUSES PARANASAL < 3 VIEWS,70210,HCPCS,320,RC,1170432,CDM,,,TC,OUTPATIENT,,, 197.33, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 167.73,,OUTPCT LIMIT, 116.92,OTHER, 84.85, 193.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45669,XR SINUSES PARANASAL < 3 VIEWS - REPORT,70210,HCPCS,999,RC,630107,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45670,XR SINUSES PARANASAL COMPLETE,70220,HCPCS,320,RC,1170434,CDM,,,TC,OUTPATIENT,,, 546.03, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 464.13,,OUTPCT LIMIT, 299.54,OTHER, 138.19, 535.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45671,REPORT XR SINUSES PARANASAL COMPLETE,70220,HCPCS,999,RC,630101,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45672,XR SKULL < 4 VIEWS,70250,HCPCS,320,RC,1170436,CDM,,,TC,OUTPATIENT,,, 385.28, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 327.49,,OUTPCT LIMIT, 221.04,OTHER, 138.19, 377.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45673,REPORT XR SKULL < 4 VIEWS,70250,HCPCS,999,RC,630097,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45674,XR SKULL COMPLETE,70260,HCPCS,320,RC,1170438,CDM,,,TC,OUTPATIENT,,, 296.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 251.60,,OUTPCT LIMIT, 177.44,OTHER, 127.28, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45675,REPORT XR SKULL COMPLETE,70260,HCPCS,999,RC,630093,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45676,XR TMJ OPEN AND CLOSED BILATERAL,70330,HCPCS,320,RC,1170502,CDM,,,TC,OUTPATIENT,,, 103.73, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 88.17,,OUTPCT LIMIT, 71.21,OTHER, 44.60, 101.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45677,XR TMJ OPEN AND CLOSED BILATERAL - REPORT,70330,HCPCS,999,RC,629933,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45678,XR NECK SOFT TISSUE,70360,HCPCS,320,RC,1170331,CDM,,,TC,OUTPATIENT,,, 354.28, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 301.14,,OUTPCT LIMIT, 193.56,OTHER, 86.34, 347.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45679,REPORT XR NECK SOFT TISSUE,70360,HCPCS,999,RC,630308,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45680,XR ELBOW COMPLETE 3+ VIEWS RIGHT,70380,HCPCS,320,RC,1170129,CDM,,,TC|RT,OUTPATIENT,,, 415.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 353.26,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45681,CT HEAD W/O CONTRAST,70450,HCPCS,351,RC,8044363,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2488.92,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45682,CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,351,RC,1168094,CDM,,,TC,OUTPATIENT,,, 2176.48, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1850.01,,OUTPCT LIMIT, 1313.91,OTHER, 283.82, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45683,REPORT CT BRAIN/HEAD W/O CONTRAST,70450,HCPCS,999,RC,629967,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45684,CT HEAD W/O CONTRAST - REPORT,70450,HCPCS,999,RC,8044365,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45685,CT HEAD W/ CONTRAST,70460,HCPCS,351,RC,8044360,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1902.81,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45686,CT BRAIN/HEAD W/ CONTRAST,70460,HCPCS,351,RC,1168092,CDM,,,TC,OUTPATIENT,,, 2238.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1902.81,,OUTPCT LIMIT, 1196.04,OTHER, 432.18, 2193.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45687,CT HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,8044362,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45688,CT BRAIN/HEAD W/ CONTRAST - REPORT,70460,HCPCS,999,RC,629963,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45689,CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,1168090,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2488.92,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45690,CT HEAD W/ + W/O CONTRAST,70470,HCPCS,351,RC,8044357,CDM,,,TC,OUTPATIENT,,, 2928.14, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2488.92,,OUTPCT LIMIT, 1545.39,OTHER, 485.27, 2869.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45691,REPORT CT BRAIN/HEAD W/ + W/O CONTRAST,70470,HCPCS,999,RC,629959,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45692,CT HEAD W/ + W/O CONTRAST - REPORT,70470,HCPCS,999,RC,8044359,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45693,CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,351,RC,1168192,CDM,,,TC,OUTPATIENT,,, 1817.73, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1545.07,,OUTPCT LIMIT, 955.20,OTHER, 283.82, 1781.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45694,REPORT CT ORBITS SELLA W/O CONTRAST,70480,HCPCS,999,RC,630106,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45695,CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,351,RC,1168190,CDM,,,TC,OUTPATIENT,,, 1205.06, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1024.30,,OUTPCT LIMIT, 691.35,OTHER, 432.18, 1180.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45696,REPORT CT ORBITS SELLA W/ CONTRAST,70481,HCPCS,999,RC,630103,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45697,CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,351,RC,1168188,CDM,,,TC,OUTPATIENT,,, 1580.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1343.00,,OUTPCT LIMIT, 887.08,OTHER, 485.27, 1548.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45698,REPORT CT ORBITS SELLA W/ + W/O CONTRAST,70482,HCPCS,999,RC,630099,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45699,CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,350,RC,1168186,CDM,,,TC,OUTPATIENT,,, 1707.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1450.95,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45700,CT SINUS W/O CONTRAST,70486,HCPCS,350,RC,1168228,CDM,,,TC,OUTPATIENT,,, 1707.38, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1451.27,,OUTPCT LIMIT, 901.22,OTHER, 283.82, 1673.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45701,REPORT CT MAXILLOFACIAL W/O CONTRAST,70486,HCPCS,999,RC,630095,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45702,CT SINUS W/O CONTRAST - REPORT,70486,HCPCS,999,RC,661604,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45703,CT SINUS W/ CONTRAST,70487,HCPCS,350,RC,8051544,CDM,,,TC,OUTPATIENT,,, 1951.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1658.92,,OUTPCT LIMIT, 1055.93,OTHER, 432.18, 1912.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45704,CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,351,RC,1168184,CDM,,,TC,OUTPATIENT,,, 2456.99, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2088.44,,OUTPCT LIMIT, 1302.68,OTHER, 432.18, 2407.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45705,REPORT CT MAXILLOFACIAL W/ CONTRAST,70487,HCPCS,999,RC,630091,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45706,CT SINUS W/ CONTRAST - REPORT,70487,HCPCS,999,RC,8047971,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45707,CT MAXILLOFACIAL W/ + W/O CONTRAST,70488,HCPCS,351,RC,1168182,CDM,,,TC,OUTPATIENT,,, 814.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 691.90,,OUTPCT LIMIT, 513.03,OTHER, 350.02, 797.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45708,CT MAXILLOFACIAL W/ + W/O CONTRAST - REPORT,70488,HCPCS,999,RC,630087,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45709,CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,350,RC,1168234,CDM,,,TC,OUTPATIENT,,, 2504.56, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2128.88,,OUTPCT LIMIT, 1290.59,OTHER, 283.82, 2454.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45710,REPORT CT NECK SOFT TISSUE W/O CONTRAST,70490,HCPCS,999,RC,630161,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45711,CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,350,RC,1168232,CDM,,,TC,OUTPATIENT,,, 2604.70, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2214.00,,OUTPCT LIMIT, 1374.81,OTHER, 432.18, 2552.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45712,REPORT CT NECK SOFT TISSUE W/ CONTRAST,70491,HCPCS,999,RC,630159,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45713,CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,350,RC,1168230,CDM,,,TC,OUTPATIENT,,, 2355.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2002.52,,OUTPCT LIMIT, 1265.96,OTHER, 485.27, 2308.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45714,REPORT CT NECK SOFT TISSUE W/ + W/O CONTRAST,70492,HCPCS,999,RC,630155,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45715,CT ANGIO BRAIN AND NECK,70496,HCPCS,351,RC,2424689,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1667.91,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45716,CT ANGIO HEAD/NECK,70496,HCPCS,351,RC,8047905,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1667.91,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45717,CT ANGIO BRAIN/HEAD,70496,HCPCS,351,RC,1167871,CDM,,,TC,OUTPATIENT,,, 1962.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1667.91,,OUTPCT LIMIT, 1076.14,OTHER, 495.38, 1923.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45718,CT ANGIO BRAIN AND NECK - REPORT,70496,HCPCS,999,RC,2424691,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45719,REPORT CT ANGIO BRAIN/HEAD,70496,HCPCS,999,RC,629763,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45720,REPORT CT ANGIO HEAD/NECK,70496,HCPCS,999,RC,8047907,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45721,CT ANGIO NECK,70498,HCPCS,351,RC,1167879,CDM,,,TC,OUTPATIENT,,, 2360.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2006.77,,OUTPCT LIMIT, 1270.81,OTHER, 495.38, 2313.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45722,REPORT CT ANGIO NECK,70498,HCPCS,999,RC,629771,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45723,MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,610,RC,1168852,CDM,,,TC,OUTPATIENT,,, 3063.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2604.12,,OUTPCT LIMIT, 1681.52,OTHER, 779.04, 3002.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45724,REPORT MRI FACE NECK ORBIT W/ + W/O CONTRAST,70543,HCPCS,999,RC,630855,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45725,MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,611,RC,1168653,CDM,,,TC,OUTPATIENT,,, 2260.39, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1921.33,,OUTPCT LIMIT, 1224.87,OTHER, 508.57, 2215.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45726,REPORT MRA BRAIN/HEAD W/O CONTRAST,70544,HCPCS,999,RC,630724,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45727,MRA BRAIN/HEAD W/ CONTRAST,70545,HCPCS,611,RC,1168651,CDM,,,TC,OUTPATIENT,,, 2411.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2049.35,,OUTPCT LIMIT, 1324.21,OTHER, 616.91, 2362.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45728,MRA BRAIN/HEAD W/ CONTRAST - REPORT,70545,HCPCS,999,RC,630722,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45729,MRA BRAIN/HEAD W/ + W/O CONTRAST,70546,HCPCS,611,RC,1168649,CDM,,,TC,OUTPATIENT,,, 2759.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2345.58,,OUTPCT LIMIT, 1532.99,OTHER, 779.04, 2704.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45730,MRA BRAIN/HEAD W/ + W/O CONTRAST - REPORT,70546,HCPCS,999,RC,630720,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45731,MRA NECK W/O CONTRAST,70547,HCPCS,610,RC,1168683,CDM,,,TC,OUTPATIENT,,, 2278.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1936.51,,OUTPCT LIMIT, 1233.59,OTHER, 508.57, 2232.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45732,REPORT MRA NECK W/O CONTRAST,70547,HCPCS,999,RC,630744,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45733,MRA NECK W/ CONTRAST,70548,HCPCS,610,RC,1168681,CDM,,,TC,OUTPATIENT,,, 2272.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1931.20,,OUTPCT LIMIT, 1256.33,OTHER, 616.91, 2226.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45734,MRA NECK W/ CONTRAST - REPORT,70548,HCPCS,999,RC,630740,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 438.95,OTHER, 187.68, 616.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45735,MRA NECK W/ + W/O CONTRAST,70549,HCPCS,610,RC,1168679,CDM,,,TC,OUTPATIENT,,, 2612.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2220.41,,OUTPCT LIMIT, 1461.09,OTHER, 779.04, 2560.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45736,MRA NECK W/ + W/O CONTRAST - REPORT,70549,HCPCS,999,RC,630738,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45737,MRI BRAIN W/O CONTRAST,70551,HCPCS,610,RC,1168800,CDM,,,TC,OUTPATIENT,,, 2647.01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2249.96,,OUTPCT LIMIT, 1413.66,OTHER, 508.57, 2594.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45738,REPORT MRI BRAIN W/O CONTRAST,70551,HCPCS,999,RC,627685,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45739,MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,610,RC,1168796,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3473.88,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45740,MRI PITUITARY W/ + W/O CONTRAST,70553,HCPCS,610,RC,9178178,CDM,,,TC,OUTPATIENT,,, 4086.92, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3473.88,,OUTPCT LIMIT, 2181.19,OTHER, 779.04, 4005.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45741,REPORT MRI BRAIN W/ + W/O CONTRAST,70553,HCPCS,999,RC,627681,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45742,MRI PITUITARY W/ + W/O CONTRAST - REPORT,70553,HCPCS,999,RC,9178180,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45743,XR CHEST 1 VIEW PORTABLE,71045,HCPCS,320,RC,8930956,CDM,,,TC,OUTPATIENT,,, 86.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.10,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45744,XR CHEST 1 VIEW,71045,HCPCS,320,RC,8044495,CDM,,,TC,OUTPATIENT,,, 86.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.10,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45745,XR BABYGRAM,71045,HCPCS,320,RC,9531177,CDM,,,TC,OUTPATIENT,,, 86.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.10,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45746,XR CHEST 1 VIEW FRONTAL,71045,HCPCS,320,RC,1170038,CDM,,,TC,OUTPATIENT,,, 86.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.10,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45747,REPORT XR CHEST 1 VIEW,71045,HCPCS,999,RC,8044496,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45748,XR CHEST 1 VIEW PORTABLE - REPORT,71045,HCPCS,999,RC,8930957,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45749,XR CHEST 1 VIEW FRONTAL - REPORT,71045,HCPCS,999,RC,629717,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45750,XR BABYGRAM - REPORT,71045,HCPCS,999,RC,9531179,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45751,XR CHEST 2 VIEWS,71046,HCPCS,320,RC,689607,CDM,,,TC,OUTPATIENT,,, 86.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.10,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45752,REPORT XR CHEST 2 VIEWS,71046,HCPCS,999,RC,629719,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45753,XR CHEST DECUBITUS,71047,HCPCS,320,RC,1170049,CDM,,,TC,OUTPATIENT,,, 86.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.10,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45754,XR CHEST 2 VIEWS W/ APICAL LORDOTIC,71047,HCPCS,320,RC,1170040,CDM,,,TC,OUTPATIENT,,, 86.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.10,,OUTPCT LIMIT, 63.51,OTHER, 36.98, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45755,XR CHEST 2 VIEWS W/ APICAL LORDOTIC - REPORT,71047,HCPCS,999,RC,629721,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45756,XR CHEST DECUBITUS - REPORT,71047,HCPCS,999,RC,1170048,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45757,XR RIBS 2 VIEWS RIGHT,71100,HCPCS,320,RC,1170373,CDM,,,TC|RT,OUTPATIENT,,, 453.59, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 385.55,,OUTPCT LIMIT, 242.05,OTHER, 86.34, 444.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45758,XR RIBS 2 VIEWS LEFT,71100,HCPCS,320,RC,1170371,CDM,,,TC|LT,OUTPATIENT,,, 456.59, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 388.10,,OUTPCT LIMIT, 243.52,OTHER, 86.34, 447.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45759,XR RIBS 2 VIEWS LEFT - REPORT,71100,HCPCS,999,RC,630230,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45760,XR RIBS 2 VIEWS RIGHT - REPORT,71100,HCPCS,999,RC,630228,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45761,XR RIBS W/ PA CHEST RIGHT,71101,HCPCS,320,RC,1170381,CDM,,,TC|RT,OUTPATIENT,,, 371.14, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 315.47,,OUTPCT LIMIT, 214.14,OTHER, 138.19, 363.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45762,XR RIBS W/ PA CHEST LEFT,71101,HCPCS,320,RC,1170379,CDM,,,TC|LT,OUTPATIENT,,, 424.16, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 360.54,,OUTPCT LIMIT, 240.03,OTHER, 138.19, 415.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45763,XR RIBS W/ PA CHEST RIGHT - REPORT,71101,HCPCS,999,RC,630218,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45764,XR RIBS W/ PA CHEST LEFT - REPORT,71101,HCPCS,999,RC,630224,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45765,XR RIBS W/ PA CHEST BILATERAL,71111,HCPCS,320,RC,1170377,CDM,,,TC|50,OUTPATIENT,,, 442.27, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 375.93,,OUTPCT LIMIT, 248.87,OTHER, 138.19, 433.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45766,XR RIBS W/ PA CHEST BILATERAL - REPORT,71111,HCPCS,999,RC,630226,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45767,XR STERNUM 2+ VIEWS,71120,HCPCS,320,RC,1170496,CDM,,,TC,OUTPATIENT,,, 296.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 251.60,,OUTPCT LIMIT, 165.10,OTHER, 86.34, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45768,REPORT XR STERNUM 2+ VIEWS,71120,HCPCS,999,RC,629975,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45769,XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,320,RC,1170494,CDM,,,TC,OUTPATIENT,,, 86.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.10,,OUTPCT LIMIT, 62.55,OTHER, 36.98, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45770,REPORT XR STERNOCLAVICULAR JOINT(S),71130,HCPCS,999,RC,629977,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45771,CT CHEST W/O CONTRAST,71250,HCPCS,350,RC,1168287,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1991.04,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45772,CT CHEST HIGH RESOLUTION,71250,HCPCS,350,RC,2424752,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1991.04,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45773,71250 CT CHEST/ABD/PELVIS W/O CONTRAST,71250,HCPCS,350,RC,9848159,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1991.04,,OUTPCT LIMIT, 1211.40,OTHER, 283.82, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45774,REPORT CT CHEST W/O CONTRAST,71250,HCPCS,999,RC,629705,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45775,CT CHEST HIGH RESOLUTION - REPORT,71250,HCPCS,999,RC,2424754,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45776,71260 CT CHEST/ABD/PELVIS W/ CONTRAST,71260,HCPCS,350,RC,9845780,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1991.04,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45777,CT CHEST W/ CONTRAST,71260,HCPCS,350,RC,1168285,CDM,,,TC,OUTPATIENT,,, 2793.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2374.49,,OUTPCT LIMIT, 1356.87,OTHER, 432.18, 2737.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45778,REPORT CT CHEST W/ CONTRAST,71260,HCPCS,999,RC,629703,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45779,CT CHEST W/ + W/O CONTRAST,71270,HCPCS,350,RC,1168283,CDM,,,TC,OUTPATIENT,,, 3484.86, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2962.13,,OUTPCT LIMIT, 1817.25,OTHER, 485.27, 3415.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45780,REPORT CT CHEST W/ + W/O CONTRAST,71270,HCPCS,999,RC,629699,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45781,CT LOW DOSE LUNG SCAN,71271,HCPCS,350,RC,8144333,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1991.04,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45782,CT LUNG CANCER SCREENING,71271,HCPCS,350,RC,2424812,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1991.04,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45783,CT LOW DOSE LUNG SCREENING,71271,HCPCS,350,RC,9513759,CDM,,,TC,OUTPATIENT,,, 2342.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1991.04,,OUTPCT LIMIT, 1171.85,OTHER, 117.71, 2295.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45784,REPORT CT LUNG CANCER SCREENING,71271,HCPCS,999,RC,2424814,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45785,CT LOW DOSE LUNG SCAN - REPORT,71271,HCPCS,999,RC,8144335,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45786,CT LOW DOSE LUNG SCREENING - REPORT,71271,HCPCS,999,RC,9515245,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 209.22,OTHER, 117.71, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45787,CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,8596597,CDM,,,TC,OUTPATIENT,,, 4980.03, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 4233.03,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45788,CT ANGIO CHEST,71275,HCPCS,350,RC,1167863,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2852.33,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45789,CT ANGIO CHEST PE PROTOCOL,71275,HCPCS,350,RC,8144330,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2852.33,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45790,71275 CT ANGIO CHEST/ABD/PELVIS,71275,HCPCS,350,RC,9845779,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2852.33,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45791,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT,71275,HCPCS,350,RC,8828516,CDM,,,TC,OUTPATIENT,,, 3355.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2852.33,,OUTPCT LIMIT, 1915.21,OTHER, 495.38, 4880.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45792,REPORT CT ANGIO ABDOMEN AND PELVIS,71275,HCPCS,999,RC,8596599,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45793,REPORT CT ANGIO CHEST,71275,HCPCS,999,RC,629701,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45794,CT ANGIO CHEST PE + ABD/PELVIS W/ CONT - REPORT,71275,HCPCS,999,RC,8828518,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45795,CT ANGIO CHEST PE PROTOCOL - REPORT,71275,HCPCS,999,RC,8144332,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45796,MRA CHEST W/ + W/O CONTRAST,71555,HCPCS,610,RC,1168643,CDM,,,TC,OUTPATIENT,,, 1266.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1076.10,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45797,MRA CHEST W/O CONTRAST,71555,HCPCS,610,RC,1168647,CDM,,,TC,OUTPATIENT,,, 2825.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2401.25,,OUTPCT LIMIT, 1310.99,OTHER, 544.38, 2768.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45798,MRA CHEST W/ + W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675667,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45799,MRA CHEST W/O CONTRAST - REPORT,71555,HCPCS,999,RC,675665,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45800,XR SPINE CERVICAL 1 VIEW,72020,HCPCS,320,RC,1170446,CDM,,,TC,OUTPATIENT,,, 304.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 258.40,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45801,XR SPINE LUMBAR 1 VIEW,72020,HCPCS,320,RC,1170448,CDM,,,TC,OUTPATIENT,,, 304.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 258.40,,OUTPCT LIMIT, 169.01,OTHER, 86.34, 297.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45802,REPORT XR SPINE LUMBAR 1 VIEW,72020,HCPCS,999,RC,630081,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45803,REPORT XR SPINE CERVICAL 1 VIEW,72020,HCPCS,999,RC,629693,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45804,XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,320,RC,1170452,CDM,,,TC,OUTPATIENT,,, 439.78, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 373.81,,OUTPCT LIMIT, 247.65,OTHER, 138.19, 430.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45805,REPORT XR SPINE CERVICAL 2 OR 3 VIEWS,72040,HCPCS,999,RC,629601,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45806,XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,320,RC,1170454,CDM,,,TC,OUTPATIENT,,, 650.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 553.01,,OUTPCT LIMIT, 350.60,OTHER, 138.19, 637.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45807,REPORT XR SPINE CERVICAL 4 OR 5 VIEWS,72050,HCPCS,999,RC,629603,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45808,XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,320,RC,1170461,CDM,,,TC,OUTPATIENT,,, 716.19, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 608.76,,OUTPCT LIMIT, 382.63,OTHER, 138.19, 701.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45809,REPORT XR SPINE CERVICAL 6+ VIEWS,72052,HCPCS,999,RC,629613,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45810,XR SPINE THORACIC 2 VIEWS,72070,HCPCS,320,RC,1170484,CDM,,,TC,OUTPATIENT,,, 533.66, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 453.61,,OUTPCT LIMIT, 293.50,OTHER, 138.19, 522.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45811,XR SPINE THORACIC 2 VIEWS - REPORT,72070,HCPCS,999,RC,630003,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45812,XR SPINE THORACIC 3 VIEWS,72072,HCPCS,320,RC,1170486,CDM,,,TC,OUTPATIENT,,, 477.06, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 405.50,,OUTPCT LIMIT, 265.86,OTHER, 138.19, 467.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45813,REPORT XR SPINE THORACIC 3 VIEWS,72072,HCPCS,999,RC,629999,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45814,XR SPINE THORACIC 4+ VIEWS,72074,HCPCS,320,RC,1170488,CDM,,,TC,OUTPATIENT,,, 263.26, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 223.77,,OUTPCT LIMIT, 161.46,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45815,XR SPINE THORACIC 4+ VIEWS - REPORT,72074,HCPCS,999,RC,629995,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45816,XR SPINE THORACOLUMBAR 2+ VIEWS,72080,HCPCS,320,RC,1170490,CDM,,,TC,OUTPATIENT,,, 250.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 212.50,,OUTPCT LIMIT, 142.64,OTHER, 86.34, 245.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45817,XR SPINE THORACOLUMBAR 2+ VIEWS - REPORT,72080,HCPCS,999,RC,629987,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45818,XR SPINE SCOLIOSIS 1 VIEW,72081,HCPCS,320,RC,7520627,CDM,,,26,OUTPATIENT,,, 86.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.10,,OUTPCT LIMIT, 63.06,OTHER, 36.98, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45819,XR SPINE SCOLIOSIS 2-3 VIEWS,72082,HCPCS,320,RC,7520630,CDM,,,TC,OUTPATIENT,,, 263.26, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 223.77,,OUTPCT LIMIT, 163.44,OTHER, 113.20, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45820,XR SPINE SCOLIOSIS 2-3 VIEWS - REPORT,72082,HCPCS,999,RC,7520632,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45821,XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,320,RC,1170470,CDM,,,TC,OUTPATIENT,,, 463.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 393.98,,OUTPCT LIMIT, 259.24,OTHER, 138.19, 454.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45822,REPORT XR SPINE LUMBOSACRAL 2 OR 3 VIEWS,72100,HCPCS,999,RC,630050,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45823,XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,320,RC,1170476,CDM,,,TC,OUTPATIENT,,, 274.42, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.26,,OUTPCT LIMIT, 166.91,OTHER, 118.00, 268.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45824,REPORT XR SPINE LUMBOSACRAL 4+ VIEWS,72110,HCPCS,999,RC,630023,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45825,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS,72114,HCPCS,320,RC,1170474,CDM,,,TC,OUTPATIENT,,, 766.27, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 651.33,,OUTPCT LIMIT, 407.08,OTHER, 138.19, 750.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45826,XR SPINE LUMBOSACRAL W/ BENDING 6+ VIEWS - REPORT,72114,HCPCS,999,RC,630029,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45827,CT SINUS W/ + W/O CONTRAST,72125,HCPCS,350,RC,8047908,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2422.68,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45828,CT SPINE CERVICAL W/ CONTRAST,72125,HCPCS,350,RC,1168238,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2422.68,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45829,CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,350,RC,1168240,CDM,,,TC,OUTPATIENT,,, 2850.21, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2422.68,,OUTPCT LIMIT, 1459.38,OTHER, 283.82, 2793.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45830,REPORT CT SPINE CERVICAL W/O CONTRAST,72125,HCPCS,999,RC,629611,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45831,CT SINUS W/ + W/O CONTRAST - REPORT,72125,HCPCS,999,RC,8047910,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45832,CT SPINE CERVICAL W/ CONTRAST - REPORT,72125,HCPCS,999,RC,629609,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45833,CT SPINE CERVICAL W/ + W/O CONTRAST,72127,HCPCS,350,RC,1168236,CDM,,,TC,OUTPATIENT,,, 1125.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 956.25,,OUTPCT LIMIT, 664.89,OTHER, 483.75, 1102.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45834,CT SPINE CERVICAL W/ + W/O CONTRAST - REPORT,72127,HCPCS,999,RC,629607,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45835,CT SPINE THORACIC W/ + W/O CONTRAST,72128,HCPCS,350,RC,1168248,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2752.95,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45836,CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,350,RC,1168252,CDM,,,TC,OUTPATIENT,,, 3238.76, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2752.95,,OUTPCT LIMIT, 1649.11,OTHER, 283.82, 3173.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45837,CT SPINE THORACIC W/ + W/O CONTRAST - REPORT,72128,HCPCS,999,RC,630166,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45838,REPORT CT SPINE THORACIC W/O CONTRAST,72128,HCPCS,999,RC,630173,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45839,CT SPINE THORACIC W/ CONTRAST,72129,HCPCS,350,RC,1168250,CDM,,,TC,OUTPATIENT,,, 3200.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2720.00,,OUTPCT LIMIT, 1665.51,OTHER, 432.18, 3136.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45840,CT SPINE THORACIC W/ CONTRAST - REPORT,72129,HCPCS,999,RC,630169,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45841,CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,350,RC,1168246,CDM,,,TC,OUTPATIENT,,, 2808.85, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2387.52,,OUTPCT LIMIT, 1439.18,OTHER, 283.82, 2752.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45842,REPORT CT SPINE LUMBAR W/O CONTRAST,72131,HCPCS,999,RC,630057,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45843,CT SPINE LUMBAR W/ CONTRAST,72132,HCPCS,350,RC,1168244,CDM,,,TC,OUTPATIENT,,, 3173.54, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2697.51,,OUTPCT LIMIT, 1652.58,OTHER, 432.18, 3110.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45844,CT SPINE LUMBAR W/ CONTRAST - REPORT,72132,HCPCS,999,RC,630053,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45845,CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,350,RC,1168242,CDM,,,TC|LT,OUTPATIENT,,, 3000.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2550.00,,OUTPCT LIMIT, 1580.48,OTHER, 485.27, 2940.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45846,REPORT CT SPINE LUMBAR W/ + W/O CONTRAST,72133,HCPCS,999,RC,630051,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45847,MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,610,RC,1169054,CDM,,,TC,OUTPATIENT,,, 3258.57, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2769.78,,OUTPCT LIMIT, 1712.29,OTHER, 508.57, 3193.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45848,REPORT MRI SPINE CERVICAL W/O CONTRAST,72141,HCPCS,999,RC,629599,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45849,MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,610,RC,1169066,CDM,,,TC,OUTPATIENT,,, 3632.28, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3087.44,,OUTPCT LIMIT, 1894.78,OTHER, 508.57, 3559.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45850,REPORT MRI SPINE THORACIC W/O CONTRAST,72146,HCPCS,999,RC,631296,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45851,MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,610,RC,1169060,CDM,,,TC,OUTPATIENT,,, 3188.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2709.97,,OUTPCT LIMIT, 1677.93,OTHER, 508.57, 3124.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45852,REPORT MRI SPINE LUMBAR W/O CONTRAST,72148,HCPCS,999,RC,631288,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45853,MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,610,RC,1169050,CDM,,,TC,OUTPATIENT,,, 3961.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3367.02,,OUTPCT LIMIT, 2119.80,OTHER, 779.04, 3881.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45854,REPORT MRI SPINE CERVICAL W/ + W/O CONTRAST,72156,HCPCS,999,RC,629595,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45855,MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,610,RC,1169062,CDM,,,TC,OUTPATIENT,,, 4820.77, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 4097.65,,OUTPCT LIMIT, 2539.54,OTHER, 779.04, 4724.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45856,REPORT MRI SPINE THORACIC W/ + W/O CONTRAST,72157,HCPCS,999,RC,631294,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45857,MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,610,RC,1169056,CDM,,,TC,OUTPATIENT,,, 4514.94, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3837.70,,OUTPCT LIMIT, 2390.20,OTHER, 779.04, 4424.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45858,REPORT MRI SPINE LUMBAR W/ + W/O CONTRAST,72158,HCPCS,999,RC,631278,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45859,MRA SPINE LUMBAR W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073718,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45860,MRA SPINE CERVICAL W/O CONTRAST - REPORT,72159,HCPCS,999,RC,8073847,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45861,MRA SPINE THORACIC W/O CONTRAST˙ - REPORT,72159,HCPCS,999,RC,8073724,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45862,XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,320,RC,1170351,CDM,,,TC,OUTPATIENT,,, 417.58, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 354.94,,OUTPCT LIMIT, 236.81,OTHER, 138.19, 409.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45863,REPORT XR PELVIS 1 OR 2 VIEWS,72170,HCPCS,999,RC,630286,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45864,XR PELVIS COMPLETE 3+ VIEWS,72190,HCPCS,320,RC,1170353,CDM,,,TC,OUTPATIENT,,, 329.63, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 280.19,,OUTPCT LIMIT, 193.87,OTHER, 138.19, 323.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45865,XR PELVIS COMPLETE 3+ VIEWS - REPORT,72190,HCPCS,999,RC,630282,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45866,CT ANGIO PELVIS,72192,HCPCS,350,RC,1167881,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2077.65,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45867,CT PELVIS W/O CONTRAST,72192,HCPCS,350,RC,1168198,CDM,,,TC,OUTPATIENT,,, 2444.29, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2077.65,,OUTPCT LIMIT, 1261.16,OTHER, 283.82, 2395.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45868,REPORT CT PELVIS W/O CONTRAST,72192,HCPCS,999,RC,630115,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45869,CT ANGIO PELVIS - REPORT,72192,HCPCS,999,RC,629773,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45870,CT PELVIS W/ CONTRAST,72193,HCPCS,350,RC,1168196,CDM,,,TC,OUTPATIENT,,, 2361.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2007.36,,OUTPCT LIMIT, 1256.10,OTHER, 432.18, 2314.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45871,REPORT CT PELVIS W/ CONTRAST,72193,HCPCS,999,RC,630113,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45872,CT PELVIS W/ + W/O CONTRAST,72194,HCPCS,350,RC,1168194,CDM,,,TC,OUTPATIENT,,, 1595.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1356.18,,OUTPCT LIMIT, 894.65,OTHER, 485.27, 1563.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45873,CT PELVIS W/ + W/O CONTRAST - REPORT,72194,HCPCS,999,RC,630109,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45874,MRI PELVIS W/O CONTRAST,72195,HCPCS,610,RC,1169028,CDM,,,TC,OUTPATIENT,,, 3338.91, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2838.07,,OUTPCT LIMIT, 1751.53,OTHER, 508.57, 3272.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45875,REPORT MRI PELVIS W/O CONTRAST,72195,HCPCS,999,RC,631210,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45876,MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,610,RC,1169024,CDM,,,TC,OUTPATIENT,,, 5004.70, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 4254.00,,OUTPCT LIMIT, 2629.35,OTHER, 779.04, 4904.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45877,REPORT MRI PELVIS W/ + W/O CONTRAST,72197,HCPCS,999,RC,631200,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45878,MRA PELVIS W/ + W/O CONTRAST,72198,HCPCS,610,RC,1168687,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1700.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45879,MRA PELVIS W/O CONTRAST,72198,HCPCS,610,RC,1168691,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1700.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45880,MRA PELVIS W/ CONTRAST,72198,HCPCS,610,RC,1168689,CDM,,,TC,OUTPATIENT,,, 2000.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1700.00,,OUTPCT LIMIT, 1281.83,OTHER, 860.00, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45881,MRA PELVIS W/ CONTRAST - REPORT,72198,HCPCS,999,RC,675686,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45882,MRA PELVIS W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675684,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45883,MRA PELVIS W/ + W/O CONTRAST - REPORT,72198,HCPCS,999,RC,675688,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45884,XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,320,RC,1170387,CDM,,,TC,OUTPATIENT,,, 294.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 250.01,,OUTPCT LIMIT, 164.19,OTHER, 86.34, 288.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45885,REPORT XR SACROILIAC JOINTS 3+ VIEWS,72200,HCPCS,999,RC,630197,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45886,XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,320,RC,1170391,CDM,,,TC,OUTPATIENT,,, 417.34, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 354.74,,OUTPCT LIMIT, 224.35,OTHER, 86.34, 408.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45887,REPORT XR SACRUM/COCCYX 2+ VIEWS,72220,HCPCS,999,RC,630187,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45888,XR CLAVICLE LEFT,73000,HCPCS,320,RC,1170075,CDM,,,TC|LT,OUTPATIENT,,, 385.31, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 327.51,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45889,XR CLAVICLE RIGHT,73000,HCPCS,320,RC,1170077,CDM,,,TC|RT,OUTPATIENT,,, 385.31, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 327.51,,OUTPCT LIMIT, 208.71,OTHER, 86.34, 377.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45890,XR CLAVICLE BILAT,73000,HCPCS,320,RC,8044500,CDM,,,TC|50,OUTPATIENT,,, 399.65, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 339.70,,OUTPCT LIMIT, 215.71,OTHER, 86.34, 391.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45891,REPORT XR CLAVICLE RIGHT,73000,HCPCS,999,RC,629755,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45892,XR CLAVICLE BILAT - REPORT,73000,HCPCS,999,RC,8044502,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45893,REPORT XR CLAVICLE LEFT,73000,HCPCS,999,RC,629753,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45894,XR SCAPULA LEFT,73010,HCPCS,320,RC,1170401,CDM,,,TC|LT,OUTPATIENT,,, 263.26, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 223.77,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45895,XR SCAPULA RIGHT,73010,HCPCS,320,RC,1170403,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 223.77,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45896,XR SCAPULA BILAT,73010,HCPCS,320,RC,8044512,CDM,,,TC|RT,OUTPATIENT,,, 263.26, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 223.77,,OUTPCT LIMIT, 149.11,OTHER, 86.34, 257.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45897,REPORT XR SCAPULA LEFT,73010,HCPCS,999,RC,630167,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45898,XR SCAPULA BILAT - REPORT,73010,HCPCS,999,RC,8044514,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45899,REPORT XR SCAPULA RIGHT,73010,HCPCS,999,RC,630163,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45900,XR SHOULDER 1 VIEW BILATERAL,73020,HCPCS,320,RC,8093240,CDM,,,TC|50,OUTPATIENT,,, 318.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 270.30,,OUTPCT LIMIT, 175.84,OTHER, 86.34, 311.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45901,XR SHOULDER 1 VIEW RIGHT,73020,HCPCS,320,RC,1170411,CDM,,,TC|RT,OUTPATIENT,,, 304.11, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 258.49,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45902,XR SHOULDER 1 VIEW LEFT,73020,HCPCS,320,RC,1170409,CDM,,,TC|LT,OUTPATIENT,,, 304.11, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 258.49,,OUTPCT LIMIT, 169.06,OTHER, 86.34, 298.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45903,XR SHOULDER 1 VIEW BILATERAL - REPORT,73020,HCPCS,999,RC,8093241,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45904,XR SHOULDER 1 VIEW RIGHT - REPORT,73020,HCPCS,999,RC,630143,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45905,XR SHOULDER 1 VIEW LEFT - REPORT,73020,HCPCS,999,RC,630147,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45906,XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,320,RC,1170415,CDM,,,TC|LT,OUTPATIENT,,, 414.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 351.90,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45907,XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,320,RC,1170417,CDM,,,TC|RT,OUTPATIENT,,, 414.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 351.90,,OUTPCT LIMIT, 235.06,OTHER, 138.19, 405.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45908,XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,320,RC,8044515,CDM,,,TC|50,OUTPATIENT,,, 424.84, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.11,,OUTPCT LIMIT, 240.36,OTHER, 138.19, 416.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45909,REPORT XR SHOULDER COMPLETE 2+ VIEWS RIGHT,73030,HCPCS,999,RC,630123,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45910,REPORT XR SHOULDER COMPLETE 2+ VIEWS LEFT,73030,HCPCS,999,RC,630127,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45911,REPORT XR SHOULDER COMPLETE 2+ VIEWS BILAT,73030,HCPCS,999,RC,8044517,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45912,XR HUMERUS BILAT,73060,HCPCS,320,RC,8093237,CDM,,,TC|50,OUTPATIENT,,, 407.82, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 346.65,,OUTPCT LIMIT, 219.70,OTHER, 86.34, 399.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45913,XR HUMERUS RIGHT,73060,HCPCS,320,RC,1170247,CDM,,,TC|RT,OUTPATIENT,,, 397.07, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 337.51,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45914,XR HUMERUS LEFT,73060,HCPCS,320,RC,1170245,CDM,,,TC|LT,OUTPATIENT,,, 397.07, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 337.51,,OUTPCT LIMIT, 214.45,OTHER, 86.34, 389.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45915,REPORT XR HUMERUS BILAT,73060,HCPCS,999,RC,8093239,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45916,REPORT XR HUMERUS LEFT,73060,HCPCS,999,RC,630430,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45917,REPORT XR HUMERUS RIGHT,73060,HCPCS,999,RC,630428,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45918,XR ELBOW 2 VIEWS LEFT,73070,HCPCS,320,RC,1170121,CDM,,,TC|LT,OUTPATIENT,,, 380.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 323.77,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45919,XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,320,RC,1170119,CDM,,,TC|50,OUTPATIENT,,, 391.65, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 332.90,,OUTPCT LIMIT, 211.81,OTHER, 86.34, 383.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45920,XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,320,RC,1170123,CDM,,,TC|RT,OUTPATIENT,,, 380.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 323.77,,OUTPCT LIMIT, 206.56,OTHER, 86.34, 373.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45921,REPORT XR ELBOW 2 VIEWS BILATERAL,73070,HCPCS,999,RC,630692,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45922,REPORT XR ELBOW 2 VIEWS RIGHT,73070,HCPCS,999,RC,630688,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45923,REPORT XR ELBOW 2 VIEWS LEFT,73070,HCPCS,999,RC,630690,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45924,XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,320,RC,1170125,CDM,,,TC|50,OUTPATIENT,,, 429.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 364.65,,OUTPCT LIMIT, 230.04,OTHER, 86.34, 420.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45925,XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,320,RC,1170127,CDM,,,TC|LT,OUTPATIENT,,, 415.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 353.26,,OUTPCT LIMIT, 223.50,OTHER, 86.34, 407.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45926,REPORT XR ELBOW COMPLETE 3+ VIEWS LEFT,73080,HCPCS,999,RC,630684,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45927,REPORT XR ELBOW COMPLETE 3+ VIEWS RIGHT,73080,HCPCS,999,RC,630680,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45928,REPORT XR ELBOW COMPLETE 3+ VIEWS BILATERAL,73080,HCPCS,999,RC,630686,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45929,XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,320,RC,1170199,CDM,,,TC|RT,OUTPATIENT,,, 430.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 366.01,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45930,XR FOREARM 2 VIEWS LEFT,73090,HCPCS,320,RC,1170197,CDM,,,TC|LT,OUTPATIENT,,, 430.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 366.01,,OUTPCT LIMIT, 230.83,OTHER, 86.34, 421.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45931,XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,320,RC,1170195,CDM,,,TC|50,OUTPATIENT,,, 444.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 377.40,,OUTPCT LIMIT, 237.37,OTHER, 86.34, 435.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45932,REPORT XR FOREARM 2 VIEWS RIGHT,73090,HCPCS,999,RC,630520,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45933,REPORT XR FOREARM 2 VIEWS LEFT,73090,HCPCS,999,RC,630524,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45934,REPORT XR FOREARM 2 VIEWS BILATERAL,73090,HCPCS,999,RC,630528,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45935,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT,73092,HCPCS,320,RC,1170560,CDM,,,TC|RT,OUTPATIENT,,, 137.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 116.45,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45936,XR UPPER EXTREMITY INFANT (0-1YR) BILAT,73092,HCPCS,320,RC,1170556,CDM,,,TC|50,OUTPATIENT,,, 190.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 161.50,,OUTPCT LIMIT, 125.68,OTHER, 81.70, 186.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45937,XR UPPER EXTREMITY INFANT (0-1YR) LEFT,73092,HCPCS,320,RC,1170558,CDM,,,TC|LT,OUTPATIENT,,, 137.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 116.45,,OUTPCT LIMIT, 99.80,OTHER, 58.91, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45938,XR UPPER EXTREMITY INFANT (0-1YR) RIGHT - REPORT,73092,HCPCS,999,RC,613593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45939,XR UPPER EXTREMITY INFANT (0-1YR) BILAT - REPORT,73092,HCPCS,999,RC,613589,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45940,XR UPPER EXTREMITY INFANT (0-1YR) LEFT - REPORT,73092,HCPCS,999,RC,613591,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45941,XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,320,RC,1170604,CDM,,,TC|50,OUTPATIENT,,, 395.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 336.26,,OUTPCT LIMIT, 213.73,OTHER, 86.34, 387.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45942,XR WRIST 2 VIEWS RIGHT,73100,HCPCS,320,RC,1170608,CDM,,,TC|RT,OUTPATIENT,,, 383.31, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 325.81,,OUTPCT LIMIT, 207.73,OTHER, 86.34, 375.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45943,XR WRIST 2 VIEWS LEFT,73100,HCPCS,320,RC,1170606,CDM,,,TC|LT,OUTPATIENT,,, 383.32, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 325.82,,OUTPCT LIMIT, 207.74,OTHER, 86.34, 375.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45944,REPORT XR WRIST 2 VIEWS RIGHT,73100,HCPCS,999,RC,613635,CDM,,,TC|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45945,REPORT XR WRIST 2 VIEWS BILATERAL,73100,HCPCS,999,RC,613631,CDM,,,TC|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45946,REPORT XR WRIST 2 VIEWS LEFT,73100,HCPCS,999,RC,613633,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45947,XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,320,RC,1170614,CDM,,,TC|RT,OUTPATIENT,,, 445.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 378.82,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45948,XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,320,RC,1170610,CDM,,,TC|50,OUTPATIENT,,, 456.43, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 387.97,,OUTPCT LIMIT, 243.44,OTHER, 86.34, 447.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45949,XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,320,RC,1170612,CDM,,,TC|LT,OUTPATIENT,,, 445.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 378.82,,OUTPCT LIMIT, 238.18,OTHER, 86.34, 436.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45950,REPORT XR WRIST COMPLETE 3+ VIEWS RIGHT,73110,HCPCS,999,RC,611595,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45951,REPORT XR WRIST COMPLETE 3+ VIEWS BILATERAL,73110,HCPCS,999,RC,611599,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45952,REPORT XR WRIST COMPLETE 3+ VIEWS LEFT,73110,HCPCS,999,RC,611597,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45953,XR HAND 2 VIEWS BILATERAL,73120,HCPCS,320,RC,1170213,CDM,,,TC|50,OUTPATIENT,,, 421.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 357.85,,OUTPCT LIMIT, 238.48,OTHER, 138.19, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45954,XR HAND 2 VIEWS RIGHT,73120,HCPCS,320,RC,1170217,CDM,,,TC|RT,OUTPATIENT,,, 407.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 346.46,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45955,XR HAND 2 VIEWS LEFT,73120,HCPCS,320,RC,1170215,CDM,,,TC|LT,OUTPATIENT,,, 407.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 346.46,,OUTPCT LIMIT, 231.94,OTHER, 138.19, 399.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45956,REPORT XR HAND 2 VIEWS BILATERAL,73120,HCPCS,999,RC,630500,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45957,REPORT XR HAND 2 VIEWS LEFT,73120,HCPCS,999,RC,630494,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45958,REPORT XR HAND 2 VIEWS RIGHT,73120,HCPCS,999,RC,630490,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45959,XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,320,RC,1170223,CDM,,,TC|RT,OUTPATIENT,,, 409.16, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 347.79,,OUTPCT LIMIT, 220.36,OTHER, 86.34, 400.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45960,XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,320,RC,1170221,CDM,,,TC|LT,OUTPATIENT,,, 409.29, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 347.90,,OUTPCT LIMIT, 220.42,OTHER, 86.34, 401.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45961,XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,320,RC,1170219,CDM,,,TC|50,OUTPATIENT,,, 420.04, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 357.03,,OUTPCT LIMIT, 225.67,OTHER, 86.34, 411.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45962,REPORT XR HAND COMPLETE 3+ VIEWS BILATERAL,73130,HCPCS,999,RC,630484,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45963,REPORT XR HAND COMPLETE 3+ VIEWS RIGHT,73130,HCPCS,999,RC,630475,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45964,REPORT XR HAND COMPLETE 3+ VIEWS LEFT,73130,HCPCS,999,RC,630480,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45965,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998599,CDM,,,TC|LT,OUTPATIENT,,, 340.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 289.77,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45966,XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,320,RC,8404063,CDM,,,TC|50,OUTPATIENT,,, 315.65, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 268.30,,OUTPCT LIMIT, 174.69,OTHER, 86.34, 309.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45967,XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,8044508,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 259.17,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45968,XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,320,RC,8044506,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 259.17,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45969,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998614,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 259.17,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45970,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998611,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 259.17,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45971,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998608,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 259.17,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45972,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998605,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 259.17,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45973,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998602,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 259.17,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45974,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998596,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 259.17,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45975,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998593,CDM,,,TC|F1,OUTPATIENT,,, 304.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 259.17,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45976,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT,73140,HCPCS,320,RC,7998590,CDM,,,TC|RT,OUTPATIENT,,, 304.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 259.17,,OUTPCT LIMIT, 169.45,OTHER, 86.34, 298.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45977,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT,73140,HCPCS,320,RC,7998587,CDM,,,TC|LT,OUTPATIENT,,, 304.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 259.17,,OUTPCT LIMIT, 172.96,OTHER, 86.34, 334.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45978,XR FINGER(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998589,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45979,REPORT XR FINGER(S) 2+ VIEWS RIGHT,73140,HCPCS,999,RC,8044509,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45980,REPORT XR FINGER(S) 2+ VIEWS LEFT,73140,HCPCS,999,RC,8044507,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45981,XR FINGER(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998616,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45982,XR FINGER(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998613,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45983,XR FINGER(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998610,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45984,REPORT XR FINGER(S) 2+ VIEWS BILAT,73140,HCPCS,999,RC,8404065,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45985,XR FINGER(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998604,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45986,XR FINGER(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998601,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45987,XR FINGER(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998598,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45988,XR FINGER(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998595,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45989,XR FINGER(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73140,HCPCS,999,RC,7998592,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45990,XR FINGER(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73140,HCPCS,999,RC,7998607,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45991,CT UPPER EXTREMITY W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168325,CDM,,,TC|RT,OUTPATIENT,,, 1891.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1607.92,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45992,CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,350,RC,8102895,CDM,,,TC|50,OUTPATIENT,,, 2034.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1729.34,,OUTPCT LIMIT, 1061.06,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45993,CT ELBOW W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168002,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1729.34,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45994,CT ELBOW W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168004,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1729.34,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45995,CT FOREARM W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056036,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1729.34,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45996,CT HAND W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168086,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1729.34,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45997,CT HUMERUS W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056054,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1729.34,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45998,CT HUMERUS W/O CONTRAST RIGHT,73200,HCPCS,350,RC,8056056,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 568.65,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 45999,CT HAND W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168088,CDM,,,TC|RT,OUTPATIENT,,, 669.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 568.65,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46000,CT SHOULDER W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168220,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1729.34,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46001,CT SHOULDER W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168222,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1729.34,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46002,CT FOREARM W/O CONTRAST LEFT,73200,HCPCS,350,RC,8056034,CDM,,,TC|LT,OUTPATIENT,,, 669.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 568.65,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46003,CT WRIST W/O CONTRAST RIGHT,73200,HCPCS,350,RC,1168343,CDM,,,TC|RT,OUTPATIENT,,, 2034.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1729.34,,OUTPCT LIMIT, 860.58,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46004,CT WRIST W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168341,CDM,,,TC|LT,OUTPATIENT,,, 2034.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1729.34,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46005,CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,350,RC,1168323,CDM,,,TC|LT,OUTPATIENT,,, 1891.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1607.92,,OUTPCT LIMIT, 955.84,OTHER, 283.82, 1993.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46006,CT WRIST W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630264,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46007,CT WRIST W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630262,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46008,CT SHOULDER W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,630153,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46009,CT SHOULDER W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,630149,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46010,CT HUMERUS W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056057,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46011,CT HUMERUS W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056055,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46012,CT HAND W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629955,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46013,CT HAND W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629951,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46014,CT FOREARM W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,8056037,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46015,CT FOREARM W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,8056035,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46016,CT ELBOW W/O CONTRAST RIGHT - REPORT,73200,HCPCS,999,RC,629837,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46017,CT ELBOW W/O CONTRAST LEFT - REPORT,73200,HCPCS,999,RC,629835,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46018,REPORT CT UPPER EXTREMITY W/O CONTRAST BILAT,73200,HCPCS,999,RC,8102896,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46019,REPORT CT UPPER EXTREMITY W/O CONTRAST LEFT,73200,HCPCS,999,RC,630242,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46020,CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,350,RC,1168311,CDM,,,TC|LT,OUTPATIENT,,, 2828.99, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2404.64,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46021,CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,350,RC,1168313,CDM,,,TC|RT,OUTPATIENT,,, 2828.99, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2404.64,,OUTPCT LIMIT, 1484.34,OTHER, 432.18, 2772.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46022,REPORT CT UPPER EXTREMITY W/ CONTRAST LEFT,73201,HCPCS,999,RC,630223,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46023,REPORT CT UPPER EXTREMITY W/ CONTRAST RIGHT,73201,HCPCS,999,RC,630236,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46024,REPORT CT UPPER EXTREMITY W/O CONTRAST RIGHT,73201,HCPCS,999,RC,630244,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46025,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT,73202,HCPCS,350,RC,8102893,CDM,,,TC,OUTPATIENT,,, 1349.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1146.65,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46026,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT,73202,HCPCS,350,RC,1168317,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1146.65,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46027,CT UPPER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73202,HCPCS,972,RC,630212,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46028,CT UPPER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73202,HCPCS,999,RC,8102894,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46029,MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,610,RC,1169122,CDM,,,TC|RT,OUTPATIENT,,, 1913.65, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1626.60,,OUTPCT LIMIT, 1055.55,OTHER, 508.57, 1875.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46030,REPORT MRI UPPER EXTREMITY W/O CONTRAST RIGHT,73218,HCPCS,999,RC,631410,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46031,MRI FOREARM W/ + W/O CONTRAST BILAT,73220,HCPCS,610,RC,8142812,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2805.21,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46032,MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,610,RC,1169108,CDM,,,TC|LT,OUTPATIENT,,, 3300.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2805.21,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46033,MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,610,RC,1169110,CDM,,,TC|RT,OUTPATIENT,,, 3300.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2805.21,,OUTPCT LIMIT, 1797.05,OTHER, 779.04, 3234.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46034,MRI FOREARM W/ + W/O CONTRAST BILAT - REPORT,73220,HCPCS,999,RC,8142814,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46035,REPORT MRI UPPER EXTREMITY W/ + W/O CNT RIGHT,73220,HCPCS,999,RC,631361,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46036,REPORT MRI UPPER EXTREMITY W/ + W/O CNT LEFT,73220,HCPCS,999,RC,631357,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46037,MRI SHOULDER W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169046,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46038,MRI WRIST W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169140,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46039,MRI WRIST W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1169142,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46040,MRI ELBOW W/O CONTRAST BILAT,73221,HCPCS,610,RC,8142794,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46041,MRI ELBOW W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168848,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46042,MRI ELBOW W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168850,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46043,MRI FOREARM W/O CONTRAST LEFT,73221,HCPCS,610,RC,8060008,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46044,MRI FOREARM W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8060010,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46045,MRI HAND W/O CONTRAST LEFT,73221,HCPCS,610,RC,1168930,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46046,MRI HAND W/O CONTRAST RIGHT,73221,HCPCS,610,RC,1168932,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46047,MRI HUMERUS W/O CONTRAST LEFT,73221,HCPCS,610,RC,8053237,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46048,MRI HUMERUS W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8053239,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46049,MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,610,RC,8044423,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46050,MRI SHOULDER W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169044,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46051,MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,610,RC,1169120,CDM,,,TC|LT,OUTPATIENT,,, 3364.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46052,MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,610,RC,8044426,CDM,,,TC|RT,OUTPATIENT,,, 3364.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2859.97,,OUTPCT LIMIT, 1764.11,OTHER, 508.57, 3297.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46053,REPORT MRI UPPER EXTREMITY W/O CONTRAST LEFT,73221,HCPCS,999,RC,631403,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46054,REPORT MRI UE JOINT W/O CONTRAST RIGHT,73221,HCPCS,999,RC,8044428,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46055,REPORT MRI UE JOINT W/O CONTRAST LEFT,73221,HCPCS,999,RC,8044425,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46056,MRI ELBOW W/O CONTRAST BILAT - REPORT,73221,HCPCS,999,RC,8142796,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46057,MRI WRIST W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631466,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46058,MRI WRIST W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631484,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46059,MRI SHOULDER W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,631253,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46060,MRI SHOULDER W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,631247,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46061,MRI HUMERUS W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8053240,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46062,MRI HUMERUS W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8053238,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46063,MRI HAND W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630977,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46064,MRI HAND W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630974,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46065,MRI ELBOW W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,630846,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46066,MRI ELBOW W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,630850,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46067,MRI FOREARM W/O CONTRAST LEFT - REPORT,73221,HCPCS,999,RC,8060009,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 394.54,OTHER, 143.52, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46068,MRI FOREARM W/O CONTRAST RIGHT - REPORT,73221,HCPCS,999,RC,8060011,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46069,MRI UE JOINT W/ + W/O CONTRAST LEFT,73223,HCPCS,610,RC,8044414,CDM,,,TC|LT,OUTPATIENT,,, 2590.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2201.71,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46070,MRI UE JOINT W/ + W/O CONTRAST RIGHT,73223,HCPCS,610,RC,8044417,CDM,,,TC|RT,OUTPATIENT,,, 2590.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2201.71,,OUTPCT LIMIT, 1450.34,OTHER, 779.04, 2538.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46071,MRI UE JOINT W/ + W/O CONTRAST RIGHT - REPORT,73223,HCPCS,999,RC,8044419,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46072,MRI UE JOINT W/ + W/O CONTRAST LEFT - REPORT,73223,HCPCS,999,RC,8044416,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46073,MRA UPPER EXTREMITY W/O CONTRAST RIGHT - REPORT,73225,HCPCS,999,RC,1168727,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46074,MRA UPPER EXTREMITY W/O CONTRAST LEFT - REPORT,73225,HCPCS,999,RC,1168724,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46075,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73225,HCPCS,999,RC,1168709,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46076,MRA UPPER EXTREMITY W/ + W/O CNT LEFT - REPORT,73225,HCPCS,999,RC,1168706,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46077,XR HIP 1 VIEW W/ AP PELVIS RIGHT,73501,HCPCS,320,RC,7520579,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 306.24,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46078,XR HIP 1 VIEW RIGHT,73501,HCPCS,320,RC,1170227,CDM,,,TC|RT,OUTPATIENT,,, 360.28, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 306.24,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46079,XR HIP 1 VIEW LEFT,73501,HCPCS,320,RC,1170225,CDM,,,TC|LT,OUTPATIENT,,, 360.28, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 306.24,,OUTPCT LIMIT, 196.99,OTHER, 88.46, 353.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46080,XR HIP 1 VIEW RIGHT - REPORT,73501,HCPCS,999,RC,630466,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46081,XR HIP 1 VIEW LEFT - REPORT,73501,HCPCS,999,RC,630470,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46082,XR HIP 1 VIEW W/ AP PELVIS RIGHT - REPORT,73501,HCPCS,999,RC,7520581,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46083,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520544,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 295.77,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46084,XR HIP 2-3 VIEWS RIGHT,73502,HCPCS,320,RC,7520585,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 295.77,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46085,XR HIP 2-3 VIEWS LEFT,73502,HCPCS,320,RC,7520582,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 295.77,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46086,XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,320,RC,7520588,CDM,,,TC|LT,OUTPATIENT,,, 347.97, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 295.77,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46087,XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,320,RC,7520591,CDM,,,TC|RT,OUTPATIENT,,, 347.97, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 295.77,,OUTPCT LIMIT, 190.98,OTHER, 88.46, 341.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46088,REPORT XR HIP 2-3 VIEWS W/AP PELVIS LEFT,73502,HCPCS,999,RC,7520590,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46089,REPORT XR HIP 2-3 VIEWS W/AP PELVIS RIGHT,73502,HCPCS,999,RC,7520593,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46090,XR HIP 2-3 VIEWS LEFT - REPORT,73502,HCPCS,999,RC,7520584,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46091,XR HIP 2-3 VIEWS RIGHT - REPORT,73502,HCPCS,999,RC,7520587,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46092,XR HIPS 2 VIEWS BILAT,73521,HCPCS,320,RC,7520606,CDM,,,TC|50,OUTPATIENT,,, 455.18, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 386.90,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46093,XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,320,RC,7520609,CDM,,,TC|50,OUTPATIENT,,, 361.97, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 307.67,,OUTPCT LIMIT, 234.40,OTHER, 146.51, 446.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46094,XR HIPS 2 VIEWS BILAT - REPORT,73521,HCPCS,999,RC,7520608,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46095,REPORT XR HIPS 2 VIEWS W/AP PELVIS BILAT,73521,HCPCS,999,RC,7520611,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 96.05,OTHER, 37.54, 146.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46096,XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,320,RC,7520573,CDM,,,TC|RT,OUTPATIENT,,, 372.54, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 316.66,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46097,XR FEMUR 2 VIEWS LEFT,73552,HCPCS,320,RC,7520570,CDM,,,TC|LT,OUTPATIENT,,, 372.54, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 316.66,,OUTPCT LIMIT, 202.98,OTHER, 88.46, 365.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46098,XR FEMUR 2 VIEWS BILAT,73552,HCPCS,320,RC,8044503,CDM,,,TC|50,OUTPATIENT,,, 383.29, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 325.80,,OUTPCT LIMIT, 208.23,OTHER, 88.46, 375.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46099,REPORT XR FEMUR 2 VIEWS BILAT,73552,HCPCS,999,RC,8044505,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46100,REPORT XR FEMUR 2 VIEWS RIGHT,73552,HCPCS,999,RC,7520575,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46101,REPORT XR FEMUR 2 VIEWS LEFT,73552,HCPCS,999,RC,7520572,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 75.32,OTHER, 37.54, 88.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46102,XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,320,RC,1170261,CDM,,,TC|50,OUTPATIENT,,, 389.44, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 331.02,,OUTPCT LIMIT, 210.73,OTHER, 86.34, 381.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46103,XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,320,RC,1170263,CDM,,,TC|LT,OUTPATIENT,,, 377.16, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 320.59,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46104,XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,320,RC,1170265,CDM,,,TC|RT,OUTPATIENT,,, 377.16, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 320.59,,OUTPCT LIMIT, 204.73,OTHER, 86.34, 369.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46105,REPORT XR KNEE 1 OR 2 VIEWS RIGHT,73560,HCPCS,999,RC,630357,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46106,REPORT XR KNEE 1 OR 2 VIEWS BILATERAL,73560,HCPCS,999,RC,630366,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46107,REPORT XR KNEE 1 OR 2 VIEWS LEFT,73560,HCPCS,999,RC,630362,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46108,XR KNEE 3 VIEWS LEFT,73562,HCPCS,320,RC,1170269,CDM,,,TC|LT,OUTPATIENT,,, 483.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 411.26,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46109,XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,320,RC,1170267,CDM,,,TC|50,OUTPATIENT,,, 494.58, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 420.39,,OUTPCT LIMIT, 274.41,OTHER, 138.19, 484.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46110,XR KNEE 3 VIEWS RIGHT,73562,HCPCS,320,RC,1170271,CDM,,,TC|RT,OUTPATIENT,,, 483.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 411.26,,OUTPCT LIMIT, 269.16,OTHER, 138.19, 474.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46111,REPORT XR KNEE 3 VIEWS BILATERAL,73562,HCPCS,999,RC,630416,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46112,REPORT XR KNEE 3 VIEWS RIGHT,73562,HCPCS,999,RC,630396,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46113,REPORT XR KNEE 3 VIEWS LEFT,73562,HCPCS,999,RC,630404,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46114,XR KNEE COMPLETE 4+ VIEWS BILATERAL,73564,HCPCS,320,RC,1170285,CDM,,,TC|50,OUTPATIENT,,, 756.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 642.60,,OUTPCT LIMIT, 402.07,OTHER, 138.19, 740.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46115,XR KNEE COMPLETE 4+ VIEWS LEFT,73564,HCPCS,320,RC,1170287,CDM,,,TC|LT,OUTPATIENT,,, 742.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 630.91,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46116,XR KNEE COMPLETE 4+ VIEWS RIGHT,73564,HCPCS,320,RC,1170289,CDM,,,TC|RT,OUTPATIENT,,, 742.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 630.91,,OUTPCT LIMIT, 395.36,OTHER, 138.19, 727.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46117,XR KNEE COMPLETE 4+ VIEWS BILATERAL - REPORT,73564,HCPCS,999,RC,630392,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46118,XR KNEE COMPLETE 4+ VIEWS RIGHT - REPORT,73564,HCPCS,999,RC,630370,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46119,XR KNEE COMPLETE 4+ VIEWS LEFT - REPORT,73564,HCPCS,999,RC,630374,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46120,XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,320,RC,1170291,CDM,,,TC,OUTPATIENT,,, 271.98, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 231.18,,OUTPCT LIMIT, 153.37,OTHER, 86.34, 266.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46121,REPORT XR KNEE 1 VIEW STANDING AP BILATERAL,73565,HCPCS,999,RC,630352,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46122,XR TIBIA/FIBULA BILATERAL,73590,HCPCS,320,RC,1170514,CDM,,,TC|50,OUTPATIENT,,, 455.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 387.33,,OUTPCT LIMIT, 243.07,OTHER, 86.34, 446.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46123,XR TIBIA/FIBULA RIGHT,73590,HCPCS,320,RC,1170518,CDM,,,TC|RT,OUTPATIENT,,, 444.93, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 378.19,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46124,XR TIBIA/FIBULA LEFT,73590,HCPCS,320,RC,1170516,CDM,,,TC|LT,OUTPATIENT,,, 444.93, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 378.19,,OUTPCT LIMIT, 237.82,OTHER, 86.34, 436.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46125,REPORT XR TIBIA/FIBULA BILATERAL,73590,HCPCS,999,RC,629947,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46126,REPORT XR TIBIA/FIBULA LEFT,73590,HCPCS,999,RC,629943,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46127,REPORT XR TIBIA/FIBULA RIGHT,73590,HCPCS,999,RC,629937,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46128,XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,320,RC,1170299,CDM,,,TC|RT,OUTPATIENT,,, 86.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.10,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46129,XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,320,RC,1170297,CDM,,,TC|LT,OUTPATIENT,,, 86.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.10,,OUTPCT LIMIT, 74.90,OTHER, 36.98, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46130,XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,320,RC,1170295,CDM,,,TC|50,OUTPATIENT,,, 172.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 146.20,,OUTPCT LIMIT, 116.89,OTHER, 73.96, 168.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46131,REPORT XR LOWER EXTREMITY INFANT (0-1YR) LEFT,73592,HCPCS,999,RC,630344,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46132,REPORT XR LOWER EXTREMITY INFANT (0-1YR) RIGHT,73592,HCPCS,999,RC,630342,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46133,REPORT XR LOWER EXTREMITY INFANT (0-1YR) BILAT,73592,HCPCS,999,RC,630346,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46134,XR ANKLE 2 VIEWS LEFT,73600,HCPCS,320,RC,1169936,CDM,,,TC|LT,OUTPATIENT,,, 380.99, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 323.84,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46135,XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,320,RC,1169938,CDM,,,TC|RT,OUTPATIENT,,, 380.99, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 323.84,,OUTPCT LIMIT, 218.95,OTHER, 138.19, 373.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46136,XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,320,RC,1169934,CDM,,,TC|50,OUTPATIENT,,, 394.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 334.90,,OUTPCT LIMIT, 225.30,OTHER, 138.19, 386.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46137,REPORT XR ANKLE 2 VIEWS BILATERAL,73600,HCPCS,999,RC,625717,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46138,REPORT XR ANKLE 2 VIEWS RIGHT,73600,HCPCS,999,RC,625721,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46139,REPORT XR ANKLE 2 VIEWS LEFT,73600,HCPCS,999,RC,625719,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46140,XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,320,RC,1169940,CDM,,,TC|50,OUTPATIENT,,, 431.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 366.35,,OUTPCT LIMIT, 243.37,OTHER, 138.19, 422.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46141,XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,320,RC,1169942,CDM,,,TC|LT,OUTPATIENT,,, 417.48, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 354.86,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46142,XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,320,RC,1169944,CDM,,,TC|RT,OUTPATIENT,,, 417.48, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 354.86,,OUTPCT LIMIT, 236.76,OTHER, 138.19, 409.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46143,REPORT XR ANKLE COMPLETE 3+ VIEWS RIGHT,73610,HCPCS,999,RC,625727,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46144,REPORT XR ANKLE COMPLETE 3+ VIEWS LEFT,73610,HCPCS,999,RC,625725,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46145,REPORT XR ANKLE COMPLETE 3+ VIEWS BILATERAL,73610,HCPCS,999,RC,625723,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46146,XR FOOT 2 VIEWS LEFT,73620,HCPCS,320,RC,1170185,CDM,,,TC|LT,OUTPATIENT,,, 339.96, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 288.97,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46147,XR FOOT 2 VIEWS RIGHT,73620,HCPCS,320,RC,1170187,CDM,,,TC|RT,OUTPATIENT,,, 339.96, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 288.97,,OUTPCT LIMIT, 186.56,OTHER, 86.34, 333.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46148,REPORT XR FOOT 2 VIEWS LEFT,73620,HCPCS,999,RC,630560,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46149,REPORT XR FOOT 2 VIEWS RIGHT,73620,HCPCS,999,RC,630556,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46150,XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,320,RC,1170189,CDM,,,TC|50,OUTPATIENT,,, 470.26, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 399.72,,OUTPCT LIMIT, 250.19,OTHER, 86.34, 460.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46151,XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,320,RC,1170193,CDM,,,TC|RT,OUTPATIENT,,, 459.31, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 390.41,,OUTPCT LIMIT, 244.84,OTHER, 86.34, 450.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46152,XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,320,RC,1170191,CDM,,,TC|LT,OUTPATIENT,,, 459.51, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 390.58,,OUTPCT LIMIT, 244.94,OTHER, 86.34, 450.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46153,REPORT XR FOOT COMPLETE 3+ VIEWS RIGHT,73630,HCPCS,999,RC,630534,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46154,REPORT XR FOOT COMPLETE 3+ VIEWS BILATERAL,73630,HCPCS,999,RC,630554,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46155,REPORT XR FOOT COMPLETE 3+ VIEWS LEFT,73630,HCPCS,999,RC,630550,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46156,XR CALCANEUS BILATERAL,73650,HCPCS,320,RC,1170030,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 198.05,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46157,XR CALCANEUS LEFT,73650,HCPCS,320,RC,1170032,CDM,,,TC|LT,OUTPATIENT,,, 233.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 198.05,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46158,XR CALCANEUS RIGHT,73650,HCPCS,320,RC,1170034,CDM,,,TC|RT,OUTPATIENT,,, 233.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 198.05,,OUTPCT LIMIT, 134.33,OTHER, 86.34, 228.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46159,REPORT XR CALCANEUS LEFT,73650,HCPCS,999,RC,629619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46160,REPORT XR CALCANEUS RIGHT,73650,HCPCS,999,RC,629621,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46161,REPORT XR CALCANEUS BILATERAL,73650,HCPCS,999,RC,629617,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46162,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998644,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46163,XR TOE(5TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998641,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46164,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998638,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46165,XR TOE(2ND DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998623,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46166,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998626,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46167,XR TOE(1ST DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998617,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46168,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998632,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46169,XR TOE(4TH DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998635,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46170,XR TOE(S) 2+ VIEWS BILAT,73660,HCPCS,320,RC,8099350,CDM,,,TC|50,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 179.26,OTHER, 86.34, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46171,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT,73660,HCPCS,320,RC,7998620,CDM,,,TC|RT,OUTPATIENT,,, 311.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46172,XR TOE(3RD DIGIT) 2+ VIEWS LEFT,73660,HCPCS,320,RC,7998629,CDM,,,TC|LT,OUTPATIENT,,, 311.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 264.46,,OUTPCT LIMIT, 172.49,OTHER, 86.34, 304.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46173,XR TOE(5TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998646,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46174,XR TOE(5TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998643,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46175,XR TOE(4TH DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998640,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46176,XR TOE(4TH DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998637,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46177,XR TOE(3RD DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998634,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46178,XR TOE(3RD DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998631,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46179,XR TOE(2ND DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998628,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46180,XR TOE(S) 2+ VIEWS BILAT - REPORT,73660,HCPCS,999,RC,8099352,CDM,,,26|50,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46181,XR TOE(1ST DIGIT) 2+ VIEWS RIGHT - REPORT,73660,HCPCS,999,RC,7998622,CDM,,,26|RT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46182,XR TOE(1ST DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998619,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46183,XR TOE(2ND DIGIT) 2+ VIEWS LEFT - REPORT,73660,HCPCS,999,RC,7998625,CDM,,,26|LT,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 74.56,OTHER, 37.54, 86.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46184,CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168178,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46185,CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168180,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46186,CT TIBIA/FIBULA W/O CONTRAST LEFT,73700,HCPCS,350,RC,8055813,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46187,CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,350,RC,1168176,CDM,,,TC|50,OUTPATIENT,,, 2305.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1959.25,,OUTPCT LIMIT, 1193.14,OTHER, 283.82, 2258.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46188,CT ANKLE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1167903,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46189,CT ANKLE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1167905,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46190,CT FEMUR W/O CONTRAST LEFT,73700,HCPCS,350,RC,8056018,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46191,CT FEMUR W/O CONTRAST RIGHT,73700,HCPCS,350,RC,8056020,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46192,CT FOOT W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168040,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46193,CT FOOT W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168042,CDM,,,TC,OUTPATIENT,,, 2291.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46194,CT HIP W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168116,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46195,CT HIP W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168118,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46196,CT KNEE W/O CONTRAST LEFT,73700,HCPCS,350,RC,1168158,CDM,,,TC|LT,OUTPATIENT,,, 2291.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46197,CT KNEE W/O CONTRAST RIGHT,73700,HCPCS,350,RC,1168160,CDM,,,TC|RT,OUTPATIENT,,, 2291.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1948.16,,OUTPCT LIMIT, 1186.77,OTHER, 283.82, 2246.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46198,CT TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8055814,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46199,CT KNEE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,630047,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46200,REPORT CT LOWER EXTREMITY W/O CONTRAST RIGHT,73700,HCPCS,999,RC,630079,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46201,CT ANKLE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,625695,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46202,CT ANKLE W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,625697,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46203,REPORT CT LOWER EXTREMITY W/O CONTRAST LEFT,73700,HCPCS,999,RC,630075,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46204,CT KNEE W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,630045,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46205,CT FEMUR W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,8056019,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46206,CT FEMUR W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,8056021,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46207,CT FOOT W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629879,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46208,CT FOOT W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629881,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46209,CT HIP W/O CONTRAST LEFT - REPORT,73700,HCPCS,999,RC,629993,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46210,CT HIP W/O CONTRAST RIGHT - REPORT,73700,HCPCS,999,RC,629998,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46211,REPORT CT LOWER EXTREMITY W/O CONTRAST BILAT,73700,HCPCS,999,RC,630073,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46212,CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,350,RC,1168164,CDM,,,TC|50,OUTPATIENT,,, 2728.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2318.80,,OUTPCT LIMIT, 1435.02,OTHER, 432.18, 2673.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46213,CT LOWER EXTREMITY W/ CONTRAST LEFT,73701,HCPCS,350,RC,1168166,CDM,,,TC|LT,OUTPATIENT,,, 2714.43, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2307.27,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46214,CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,350,RC,1168168,CDM,,,TC,OUTPATIENT,,, 2714.43, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2307.27,,OUTPCT LIMIT, 1428.39,OTHER, 432.18, 2660.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46215,REPORT CT LOWER EXTREMITY W/ CONTRAST BILAT,73701,HCPCS,999,RC,630067,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46216,REPORT CT LOWER EXTREMITY W CONTRAST LEFT,73701,HCPCS,999,RC,630069,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46217,REPORT CT LOWER EXTREMITY W/ CONTRAST RIGHT,73701,HCPCS,999,RC,630071,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46218,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT,73702,HCPCS,350,RC,1168170,CDM,,,TC|50,OUTPATIENT,,, 1349.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1146.65,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46219,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT,73702,HCPCS,350,RC,1168172,CDM,,,TC|LT,OUTPATIENT,,, 1349.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1146.65,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46220,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT,73702,HCPCS,350,RC,1168174,CDM,,,TC|RT,OUTPATIENT,,, 1349.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1146.65,,OUTPCT LIMIT, 774.28,OTHER, 485.27, 1322.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46221,CT LOWER EXTREMITY W/+W/O CONTRAST LEFT - REPORT,73702,HCPCS,999,RC,630063,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46222,CT LOWER EXTREMITY W/+W/O CONTRAST BILAT - REPORT,73702,HCPCS,999,RC,630061,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46223,CT LOWER EXTREMITY W/+W/O CONTRAST RIGHT - REPORT,73702,HCPCS,999,RC,630065,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46224,CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,350,RC,1167875,CDM,,,TC|LT,OUTPATIENT,,, 1389.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1180.65,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46225,CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,350,RC,1167877,CDM,,,TC|RT,OUTPATIENT,,, 1389.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1180.65,,OUTPCT LIMIT, 796.22,OTHER, 495.38, 1361.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46226,REPORT CT ANGIO LOWER EXTREMITY RIGHT,73706,HCPCS,999,RC,629769,CDM,,,26|RT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46227,REPORT CT ANGIO LOWER EXTREMITY LEFT,73706,HCPCS,999,RC,629767,CDM,,,26|LT,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46228,MRI TIBIA/FIBULA W/O CONTRAST LEFT,73718,HCPCS,610,RC,8053249,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2515.10,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46229,MRI FOOT W/O CONTRAST RIGHT,73718,HCPCS,610,RC,1168892,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2515.10,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46230,MRI FOOT W/O CONTRAST LEFT,73718,HCPCS,610,RC,1168890,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2515.10,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46231,MRI FEMUR W/O CONTRAST RT,73718,HCPCS,610,RC,8059999,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2515.10,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46232,MRI FEMUR W/O CONTRAST LT,73718,HCPCS,610,RC,8059996,CDM,,,TC|LT,OUTPATIENT,,, 2958.94, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2515.10,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46233,MRI TIBIA/FIBULA W/O CONTRAST RIGHT,73718,HCPCS,610,RC,8053251,CDM,,,TC|RT,OUTPATIENT,,, 2958.94, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2515.10,,OUTPCT LIMIT, 1565.98,OTHER, 508.57, 2899.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46234,MRI TIBIA/FIBULA W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,8053250,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46235,MRI FOOT W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,630902,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46236,MRI FOOT W/O CONTRAST LEFT - REPORT,73718,HCPCS,999,RC,630898,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46237,MRI FEMUR W/O CONTRAST RT - REPORT,73718,HCPCS,999,RC,8060001,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46238,MRI FEMUR W/O CONTRAST LT - REPORT,73718,HCPCS,999,RC,8059998,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46239,MRI TIBIA/FIBULA W/O CONTRAST RIGHT - REPORT,73718,HCPCS,999,RC,8053252,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46240,MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,610,RC,1169022,CDM,,,TC|RT,OUTPATIENT,,, 3620.38, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3077.32,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46241,MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,610,RC,1169020,CDM,,,TC|LT,OUTPATIENT,,, 3620.38, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3077.32,,OUTPCT LIMIT, 1953.37,OTHER, 779.04, 3547.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46242,REPORT MRI LOWER EXTREMITY W/O CONTRAST LEFT,73720,HCPCS,999,RC,631191,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46243,REPORT MRI LOWER EXTREMITY W/O CONTRAST RIGHT,73720,HCPCS,999,RC,631196,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46244,MRI KNEE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168986,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2680.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46245,MRI KNEE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168984,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2680.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46246,MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,610,RC,8044408,CDM,,,TC|LT,OUTPATIENT,,, 3153.74, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2680.68,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46247,MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,610,RC,8044411,CDM,,,TC|RT,OUTPATIENT,,, 3153.74, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2680.68,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46248,MRI HIP W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168948,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2680.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46249,MRI KNEE W/ CONTRAST LEFT,73721,HCPCS,610,RC,1168978,CDM,,,LT|TC,OUTPATIENT,,, 3153.73, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2680.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46250,MRI HIP W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168950,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2680.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46251,MRI HIP W/O CONTRAST BILAT,73721,HCPCS,610,RC,8142836,CDM,,,TC,OUTPATIENT,,, 3153.73, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2680.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46252,MRI ANKLE W/O CONTRAST RIGHT,73721,HCPCS,610,RC,1168752,CDM,,,TC|RT,OUTPATIENT,,, 3153.73, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2680.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46253,MRI ANKLE W/O CONTRAST LEFT,73721,HCPCS,610,RC,1168750,CDM,,,TC|LT,OUTPATIENT,,, 3153.73, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2680.67,,OUTPCT LIMIT, 1661.10,OTHER, 508.57, 3090.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46254,MRI KNEE W/ CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631098,CDM,,,LT|26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46255,MRI HIP W/O CONTRAST BILAT - REPORT,73721,HCPCS,999,RC,8142838,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46256,MRI KNEE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631122,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46257,MRI KNEE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631114,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46258,MRI HIP W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,631008,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46259,MRI HIP W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,631012,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46260,MRI ANKLE W/O CONTRAST LEFT - REPORT,73721,HCPCS,999,RC,625713,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46261,MRI ANKLE W/O CONTRAST RIGHT - REPORT,73721,HCPCS,999,RC,625715,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46262,REPORT MRI LE JOINT W/O CONTRAST RIGHT,73721,HCPCS,999,RC,8044413,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46263,REPORT MRI LE JOINT W/O CONTRAST LEFT,73721,HCPCS,999,RC,8044410,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46264,MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,610,RC,1169010,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3912.47,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46265,MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,610,RC,8044402,CDM,,,TC|RT,OUTPATIENT,,, 4602.91, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3912.47,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46266,MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,610,RC,1169008,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3912.47,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46267,MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,8044399,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3912.47,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46268,MRI KNEE W/ + W/O CONTRAST LEFT,73723,HCPCS,610,RC,1168972,CDM,,,TC|LT,OUTPATIENT,,, 4602.91, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3912.47,,OUTPCT LIMIT, 2433.15,OTHER, 779.04, 4510.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46269,REPORT MRI LE JOINT W/ + W/O CONTRAST RIGHT,73723,HCPCS,999,RC,8044404,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46270,REPORT MRI LOWER EXTREMITY W/ + W/O CNT LEFT,73723,HCPCS,999,RC,631160,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46271,REPORT MRI LE JOINT W/ + W/O CONTRAST LEFT,73723,HCPCS,999,RC,8044401,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46272,MRI KNEE W/ + W/O CONTRAST LEFT - REPORT,73723,HCPCS,999,RC,631084,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46273,REPORT MRI LOWER EXTREMITY W/ + W/O CNT RIGHT,73723,HCPCS,999,RC,631168,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46274,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT,73725,HCPCS,610,RC,1168665,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1700.00,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46275,MRA LOWER EXTREMITY W/ + W/O CNT LEFT,73725,HCPCS,610,RC,1168663,CDM,,,TC|LT,OUTPATIENT,,, 2300.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1955.00,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46276,MRA LOWER EXTREMITY W/ + W/O CNT BILAT,73725,HCPCS,610,RC,8404030,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1955.00,,OUTPCT LIMIT, 1474.10,OTHER, 989.00, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46277,MRA LOWER EXTREMITY W/O CONTRAST RIGHT,73725,HCPCS,610,RC,1168677,CDM,,,TC|RT,OUTPATIENT,,, 1830.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1555.50,,OUTPCT LIMIT, 1227.35,OTHER, 786.90, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46278,MRA LOWER EXTREMITY W/O CONTRAST LEFT,73725,HCPCS,610,RC,1168675,CDM,,,TC|LT,OUTPATIENT,,, 1830.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1555.50,,OUTPCT LIMIT, 1323.48,OTHER, 786.90, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46279,MRA LOWER EXTREMITY W/ + W/O CNT RIGHT - REPORT,73725,HCPCS,999,RC,675682,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46280,MRA LOWER EXTREMITY W/ + W/O CNT LEFT - REPORT,73725,HCPCS,999,RC,675669,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46281,MRA LOWER EXTREMITY W/ + W/O CNT BILAT - REPORT,73725,HCPCS,999,RC,8404031,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46282,MRA LOWER EXTREMITY W/O CONTRAST RIGHT - REPORT,73725,HCPCS,999,RC,675671,CDM,,,26|RT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46283,MRA LOWER EXTREMITY W/O CONTRAST LEFT - REPORT,73725,HCPCS,999,RC,675673,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46284,XR ABDOMEN 1 VIEW,74018,HCPCS,320,RC,8044486,CDM,,,TC,OUTPATIENT,,, 166.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 141.10,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46285,XR ABDOMEN KUB 1 VIEW,74018,HCPCS,320,RC,1169926,CDM,,,TC,OUTPATIENT,,, 166.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 141.10,,OUTPCT LIMIT, 102.58,OTHER, 71.38, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46286,XR ABDOMEN KUB 1 VIEW - REPORT,74018,HCPCS,999,RC,625615,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46287,REPORT XR ABDOMEN 1 VIEW,74018,HCPCS,999,RC,8044488,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 76.00,OTHER, 37.54, 90.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46288,XR ABDOMEN 2 VIEWS,74019,HCPCS,320,RC,8044489,CDM,,,TC,OUTPATIENT,,, 86.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.10,,OUTPCT LIMIT, 83.13,OTHER, 36.98, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46289,REPORT XR ABDOMEN 2 VIEWS,74019,HCPCS,999,RC,8044491,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 105.42,OTHER, 37.54, 172.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46290,XR ABDOMEN 3 VIEWS,74022,HCPCS,320,RC,8044492,CDM,,,TC,OUTPATIENT,,, 592.92, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 503.98,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46291,XR ABDOMEN 3+ VIEWS,74022,HCPCS,320,RC,8073963,CDM,,,TC,OUTPATIENT,,, 592.92, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 503.98,,OUTPCT LIMIT, 322.43,OTHER, 138.19, 581.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46292,XR ABDOMEN 3 VIEWS - REPORT,74022,HCPCS,999,RC,8044494,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46293,XR ABDOMEN 3+ VIEWS - REPORT,74022,HCPCS,999,RC,8073965,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 93.08,OTHER, 37.54, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46294,CT ABDOMEN W/O CONTRAST,74150,HCPCS,350,RC,1167849,CDM,,,TC,OUTPATIENT,,, 2618.09, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2225.38,,OUTPCT LIMIT, 1346.03,OTHER, 283.82, 2565.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46295,REPORT CT ABDOMEN W/O CONTRAST,74150,HCPCS,999,RC,625601,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 268.54,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46296,CT ABDOMEN W/ CONTRAST,74160,HCPCS,350,RC,1167847,CDM,,,TC,OUTPATIENT,,, 2951.62, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2508.88,,OUTPCT LIMIT, 1544.22,OTHER, 432.18, 2892.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46297,REPORT CT ABDOMEN W/ CONTRAST,74160,HCPCS,999,RC,625599,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 321.53,OTHER, 143.52, 432.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46298,CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,350,RC,1167845,CDM,,,TC,OUTPATIENT,,, 3333.22, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2833.24,,OUTPCT LIMIT, 1743.20,OTHER, 485.27, 3266.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46299,REPORT CT ABDOMEN W/ + W/O CONTRAST,74170,HCPCS,999,RC,615591,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 340.49,OTHER, 143.52, 485.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46300,CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,350,RC,2424686,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 5083.03,,OUTPCT LIMIT, 3113.75,OTHER, 813.20, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46301,REPORT CT ANGIO ABDOMEN AND PELVIS,74174,HCPCS,999,RC,2424688,CDM,,,26,OUTPATIENT,,, 355.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 301.75,,OUTPCT LIMIT, 473.04,OTHER, 156.77, 813.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46302,CT ANGIO ABDOMEN,74175,HCPCS,350,RC,1167853,CDM,,,TC,OUTPATIENT,,, 3328.82, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2829.50,,OUTPCT LIMIT, 1743.46,OTHER, 495.38, 3262.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46303,REPORT CT ANGIO ABDOMEN,74175,HCPCS,999,RC,625597,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46304,CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,350,RC,2424650,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 4427.83,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46305,CT CHEST/ABD/PELVIS W/O CONTRAST,74176,HCPCS,350,RC,8044351,CDM,,,TC,OUTPATIENT,,, 5209.21, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 4427.83,,OUTPCT LIMIT, 2609.45,OTHER, 276.02, 5105.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46306,REPORT CT ABDOMEN AND PELVIS W/O CONTRAST,74176,HCPCS,999,RC,2424652,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46307,CT CHEST/ABD/PELVIS W/O CONTRAST - REPORT,74176,HCPCS,999,RC,8044353,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 265.76,OTHER, 143.52, 318.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46308,CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,350,RC,2424647,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 5083.03,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46309,CT CHEST/ABD/PELVIS W/ CONTRAST,74177,HCPCS,350,RC,8044348,CDM,,,TC,OUTPATIENT,,, 5980.03, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 5083.03,,OUTPCT LIMIT, 3021.78,OTHER, 426.91, 5860.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46310,REPORT CT ABDOMEN AND PELVIS W/ CONTRAST,74177,HCPCS,999,RC,2424649,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46311,CT CHEST/ABD/PELVIS W/ CONTRAST - REPORT,74177,HCPCS,999,RC,8044350,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 319.65,OTHER, 143.52, 426.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46312,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST,74178,HCPCS,320,RC,2424653,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 5695.18,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46313,CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,2424644,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 5695.18,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46314,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST,74178,HCPCS,350,RC,8044345,CDM,,,TC,OUTPATIENT,,, 6700.21, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 5695.18,,OUTPCT LIMIT, 3385.13,OTHER, 475.94, 6566.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46315,REPORT CT ABDOMEN AND PELVIS W/ + W/O CONTRAST,74178,HCPCS,999,RC,2424646,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46316,CT CHEST/ABD/PELVIS W/ + W/O CONTRAST - REPORT,74178,HCPCS,999,RC,8044347,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46317,CT ABDOMEN W/ + W/O + PELVIS W/ CONTRAST - REPORT,74178,HCPCS,999,RC,2424655,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 337.16,OTHER, 143.52, 475.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46318,MRI ABDOMEN W/O CONTRAST,74181,HCPCS,610,RC,1168734,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2730.41,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46319,MRI MRCP,74181,HCPCS,610,RC,8073851,CDM,,,TC,OUTPATIENT,,, 3212.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2730.41,,OUTPCT LIMIT, 1689.68,OTHER, 508.57, 3148.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46320,REPORT MRI ABDOMEN W/O CONTRAST,74181,HCPCS,999,RC,625613,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46321,REPORT MRI MRCP,74181,HCPCS,999,RC,8073853,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 400.25,OTHER, 187.68, 508.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46322,MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,610,RC,1168730,CDM,,,TC,OUTPATIENT,,, 3382.19, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2874.86,,OUTPCT LIMIT, 1837.06,OTHER, 779.04, 3314.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46323,REPORT MRI ABDOMEN W/ + W/O CONTRAST,74183,HCPCS,999,RC,625605,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 496.85,OTHER, 187.68, 779.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46324,MRA ABDOMEN W/ CONTRAST,74185,HCPCS,610,RC,1168637,CDM,,,TC,OUTPATIENT,,, 2500.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2125.00,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46325,MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,610,RC,1168635,CDM,,,TC,OUTPATIENT,,, 4048.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3440.80,,OUTPCT LIMIT, 2098.35,OTHER, 1075.00, 3967.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46326,MRA ABDOMEN W/ CONTRAST - REPORT,74185,HCPCS,999,RC,675661,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46327,MRA ABDOMEN W/O CONTRAST - REPORT,74185,HCPCS,999,RC,675663,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46328,REPORT MRA ABDOMEN W/ + W/O CONTRAST,74185,HCPCS,999,RC,675660,CDM,,,26,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46329,XR MODIFIED BARIUM SWALLOW,74230,HCPCS,320,RC,8073984,CDM,,,TC,OUTPATIENT,,, 698.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 593.30,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46330,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,7480543,CDM,,,TC,OUTPATIENT,,, 698.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 593.30,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46331,XR SWALLOWING FUNCTION W/ SPEECH,74230,HCPCS,320,RC,1170500,CDM,,,TC,OUTPATIENT,,, 698.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 593.30,,OUTPCT LIMIT, 371.17,OTHER, 127.36, 684.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46332,XR MODIFIED BARIUM SWALLOW - REPORT,74230,HCPCS,999,RC,8073986,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46333,XR SWALLOWING FUNCTION W/ SPEECH - REPORT,74230,HCPCS,999,RC,629965,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 89.21,OTHER, 37.54, 127.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46334,XR CHOLANGIOGRAM IN OR,74300,HCPCS,320,RC,1170065,CDM,,,TC,OUTPATIENT,,, 1098.53, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 933.75,,OUTPCT LIMIT, 704.06,OTHER, 472.37, 1076.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46335,XR CHOLANGIOGRAM IN OR - REPORT,74300,HCPCS,972,RC,629737,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 68.02,OTHER, 37.54, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46336,CT UROGRAM,74400,HCPCS,320,RC,8047911,CDM,,,TC,OUTPATIENT,,, 386.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 328.44,,OUTPCT LIMIT, 248.14,OTHER, 166.15, 378.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46337,CT UROGRAM - REPORT,74400,HCPCS,999,RC,8047913,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 230.64,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46338,XR CYSTOGRAM,74430,HCPCS,320,RC,4126362,CDM,,,TC,OUTPATIENT,,, 758.58, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 644.79,,OUTPCT LIMIT, 429.88,OTHER, 249.71, 743.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46339,XR CYSTOGRAM - REPORT,74430,HCPCS,999,RC,2425448,CDM,,,26,OUTPATIENT,,, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 132.91,OTHER, 37.54, 249.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46340,CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,350,RC,1167851,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2398.00,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46341,CT ANGIO ABDOMINAL AORTA WITH RUNOFF,75635,HCPCS,350,RC,8093216,CDM,,,TC|50,OUTPATIENT,,, 2821.18, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2398.00,,OUTPCT LIMIT, 1495.57,OTHER, 495.38, 2764.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46342,CT ANGIO ABDOMINAL AORTA WITH RUNOFF - REPORT,75635,HCPCS,999,RC,8093218,CDM,,,26|50,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46343,REPORT CT ANGIO ABDOMEN AORTA + ILIOFEMORAL,75635,HCPCS,999,RC,625589,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 344.10,OTHER, 143.52, 495.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46344,CT 3D RECONSTRUCTION W/O WORKSTATION,76376,HCPCS,402,RC,8044330,CDM,,,TC,OUTPATIENT,,, 350.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 297.50,,OUTPCT LIMIT, 224.32,OTHER, 150.50, 343.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46345,REPORT 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED,76376,HCPCS,999,RC,8044332,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46346,US SOFT TISSUE HEAD/NECK,76536,HCPCS,402,RC,9173558,CDM,,,TC,OUTPATIENT,,, 720.49, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 612.42,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46347,US THYROID,76536,HCPCS,402,RC,8073961,CDM,,,TC,OUTPATIENT,,, 720.49, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 612.42,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46348,US SOFT TISSUE,76536,HCPCS,402,RC,8073949,CDM,,,TC,OUTPATIENT,,, 720.49, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 612.42,,OUTPCT LIMIT, 385.53,OTHER, 141.55, 706.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46349,US SOFT TISSUE HEAD/NECK - REPORT,76536,HCPCS,999,RC,9173560,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46350,US SOFT TISSUE - REPORT,76536,HCPCS,999,RC,8073951,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46351,REPORT US THYROID,76536,HCPCS,999,RC,8073962,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46352,US CHEST,76604,HCPCS,402,RC,1169635,CDM,,,TC,OUTPATIENT,,, 542.58, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 461.19,,OUTPCT LIMIT, 286.59,OTHER, 90.89, 531.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46353,REPORT US CHEST,76604,HCPCS,999,RC,629715,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46354,US BREAST COMPLETE RIGHT,76641,HCPCS,402,RC,4645477,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 434.63,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46355,US BREAST COMPLETE LEFT,76641,HCPCS,402,RC,4645474,CDM,,,TC|LT,OUTPATIENT,,, 511.33, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 434.63,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46356,US BREAST COMPLETE RIGHT.,76641,HCPCS,402,RC,8033267,CDM,,,TC|RT,OUTPATIENT,,, 511.33, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 434.63,,OUTPCT LIMIT, 281.44,OTHER, 133.37, 501.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46357,US BREAST COMPLETE BILAT,76641,HCPCS,402,RC,8073883,CDM,,,TC|50,OUTPATIENT,,, 525.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 446.25,,OUTPCT LIMIT, 288.12,OTHER, 133.37, 514.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46358,REPORT US BREAST COMPLETE RIGHT,76641,HCPCS,999,RC,4645479,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46359,US BREAST COMPLETE RIGHT. - REPORT,76641,HCPCS,999,RC,8033269,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46360,REPORT US BREAST COMPLETE LEFT,76641,HCPCS,999,RC,4645476,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46361,REPORT US BREAST COMPLETE BILAT,76641,HCPCS,999,RC,8073885,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46362,US ABDOMEN COMPLETE,76700,HCPCS,402,RC,1169567,CDM,,,TC,OUTPATIENT,,, 962.05, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 817.74,,OUTPCT LIMIT, 503.49,OTHER, 141.55, 942.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46363,REPORT US ABDOMEN COMPLET,76700,HCPCS,999,RC,625609,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46364,US APPENDIX,76705,HCPCS,402,RC,2425293,CDM,,,TC,OUTPATIENT,,, 878.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 746.81,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46365,US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,402,RC,1169583,CDM,,,TC,OUTPATIENT,,, 878.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 746.81,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46366,US BLADDER W/ POST VOID,76705,HCPCS,402,RC,9256429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 746.81,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46367,US PYLORIS,76705,HCPCS,402,RC,8073940,CDM,,,TC,OUTPATIENT,,, 878.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 746.81,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46368,US ABDOMEN LIMITED,76705,HCPCS,402,RC,1169569,CDM,,,TC,OUTPATIENT,,, 878.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 746.81,,OUTPCT LIMIT, 462.74,OTHER, 141.55, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46369,REPORT US ABDOMEN LIMITED,76705,HCPCS,999,RC,625611,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46370,REPORT US ART/VEIN ABD/PELVIS/SCROTAL LIMITED,76705,HCPCS,999,RC,625739,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46371,US APPENDIX - REPORT,76705,HCPCS,999,RC,2425295,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46372,US BLADDER W/ POST VOID - REPORT,76705,HCPCS,999,RC,9256431,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46373,US PYLORIS - REPORT,76705,HCPCS,999,RC,8073942,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46374,US AAA SCREENING,76706,HCPCS,402,RC,8044429,CDM,,,TC,OUTPATIENT,,, 878.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 746.81,,OUTPCT LIMIT, 468.07,OTHER, 163.97, 861.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46375,US AAA SCREENING - REPORT,76706,HCPCS,999,RC,8044431,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 200.02,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46376,US KIDNEY BLADDER,76770,HCPCS,402,RC,8044453,CDM,,,TC,OUTPATIENT,,, 792.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 673.54,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46377,US RENAL,76770,HCPCS,402,RC,8305299,CDM,,,TC,OUTPATIENT,,, 792.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 673.54,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46378,US RENAL COMPLETE,76770,HCPCS,402,RC,9570199,CDM,,,TC,OUTPATIENT,,, 792.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 673.54,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46379,US AORTA,76770,HCPCS,402,RC,8044435,CDM,,,TC,OUTPATIENT,,, 792.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 673.54,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46380,US RETROPERITONEAL COMPLETE,76770,HCPCS,402,RC,1169867,CDM,,,TC,OUTPATIENT,,, 779.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 662.86,,OUTPCT LIMIT, 419.41,OTHER, 141.55, 776.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46381,US KIDNEY BLADDER - REPORT,76770,HCPCS,999,RC,8044455,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46382,REPORT US RETROPERITONEAL COMPLETE,76770,HCPCS,999,RC,630894,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46383,US RENAL COMPLETE - REPORT,76770,HCPCS,999,RC,9570201,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46384,US AORTA - REPORT,76770,HCPCS,999,RC,8044437,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46385,US RENAL - REPORT,76770,HCPCS,999,RC,8305301,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46386,US RENAL LIMITED,76775,HCPCS,402,RC,9256450,CDM,,,TC,OUTPATIENT,,, 779.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 662.86,,OUTPCT LIMIT, 414.50,OTHER, 141.55, 764.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46387,US RENAL LIMITED - REPORT,76775,HCPCS,999,RC,9256452,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46388,US SPINAL CANAL,76800,HCPCS,402,RC,1169879,CDM,,,TC,OUTPATIENT,,, 375.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 318.75,,OUTPCT LIMIT, 214.87,OTHER, 133.37, 367.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46389,US SPINAL CANAL - REPORT,76800,HCPCS,999,RC,630848,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 163.37,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46390,US OB < 14 WEEKS,76801,HCPCS,402,RC,8044462,CDM,,,TC,OUTPATIENT,,, 768.01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 652.81,,OUTPCT LIMIT, 408.73,OTHER, 141.55, 752.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46391,US OB < 14 WEEKS - REPORT,76801,HCPCS,999,RC,8044464,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46392,US OB GREATER THAN 14 WEEKS,76805,HCPCS,402,RC,1169850,CDM,,,TC,OUTPATIENT,,, 970.38, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 824.82,,OUTPCT LIMIT, 507.55,OTHER, 141.55, 950.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46393,REPORT US OB GREATER THAN 14 WEEKS,76805,HCPCS,999,RC,630920,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46394,US OB LIMITED,76815,HCPCS,402,RC,1169856,CDM,,,TC,OUTPATIENT,,, 1544.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1312.40,,OUTPCT LIMIT, 775.60,OTHER, 90.89, 1513.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46395,REPORT US OB LIMITED,76815,HCPCS,999,RC,630908,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46396,US OB FOLLOW UP,76816,HCPCS,402,RC,1169854,CDM,,,TC,OUTPATIENT,,, 530.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 450.50,,OUTPCT LIMIT, 290.56,OTHER, 133.37, 519.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46397,REPORT US OB FOLLOW UP,76816,HCPCS,999,RC,630912,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46398,US TRANSVAGINAL NON-OB,76830,HCPCS,402,RC,1169889,CDM,,,TC,OUTPATIENT,,, 790.62, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 672.03,,OUTPCT LIMIT, 419.77,OTHER, 141.55, 774.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46399,REPORT US TRANSVAGINAL NON-OB,76830,HCPCS,999,RC,630829,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46400,US PELVIC NON OB,76856,HCPCS,402,RC,8073937,CDM,,,TC,OUTPATIENT,,, 896.72, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 762.21,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46401,US PELVIS LTD W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425371,CDM,,,TC,OUTPATIENT,,, 896.72, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 762.21,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46402,US PELVIS COMP W/TRANSVAG IF INDICATED,76856,HCPCS,402,RC,2425368,CDM,,,TC,OUTPATIENT,,, 896.72, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 762.21,,OUTPCT LIMIT, 471.58,OTHER, 141.55, 878.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46403,REPORT US PELVIC NON OB,76856,HCPCS,999,RC,8073939,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46404,US PELVIS LTD W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425373,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46405,US PELVIS COMP W/TRANSVAG IF INDICATED - REPORT,76856,HCPCS,999,RC,2425370,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46406,US BLADDER SCAN,76857,HCPCS,402,RC,8058255,CDM,,,TC,OUTPATIENT,,, 625.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 531.89,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46407,US PELVIC LTD,76857,HCPCS,402,RC,8044477,CDM,,,TC,OUTPATIENT,,, 604.92, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 514.18,,OUTPCT LIMIT, 322.12,OTHER, 90.89, 613.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46408,REPORT US BLADDER SCAN,76857,HCPCS,999,RC,8058257,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46409,US PELVIC LTD - REPORT,76857,HCPCS,999,RC,8044479,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 173.92,OTHER, 90.89, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46410,US SCROTUM (CONTENTS) W/ DOPPLER IF IND,76870,HCPCS,402,RC,1169877,CDM,,,TC,OUTPATIENT,,, 767.48, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 652.36,,OUTPCT LIMIT, 408.48,OTHER, 141.55, 752.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46411,US SCROTUM (CONTENTS) W/ DOPPLER IF IND - REPORT,76870,HCPCS,999,RC,630852,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46412,US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,402,RC,3148320,CDM,,,TC|50,OUTPATIENT,,, 1600.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1360.00,,OUTPCT LIMIT, 813.95,OTHER, 137.10, 1568.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46413,US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,402,RC,2425335,CDM,,,TC|RT,OUTPATIENT,,, 1011.64, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 859.89,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46414,US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,402,RC,2425332,CDM,,,TC|LT,OUTPATIENT,,, 1011.64, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 859.89,,OUTPCT LIMIT, 526.64,OTHER, 137.10, 991.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46415,REPORT US EXTREMITY NONVASCULAR COMPLETE LEFT,76881,HCPCS,999,RC,2425334,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46416,REPORT US EXTREMITY NONVASCULAR COMPLETE RIGHT,76881,HCPCS,999,RC,2425337,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46417,REPORT US EXTREMITY NONVASCULAR COMPLETE BILAT,76881,HCPCS,999,RC,3148322,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 190.42,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46418,US GROIN RIGHT,76882,HCPCS,402,RC,9303965,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 305.12,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46419,US EXTREMITY NONVASCULAR LIMITED BILAT,76882,HCPCS,402,RC,3148326,CDM,,,TC|50,OUTPATIENT,,, 550.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 467.50,,OUTPCT LIMIT, 300.33,OTHER, 133.37, 539.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46420,US UPPER EXT NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,8243248,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 305.12,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46421,US UPPER EXT NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,8243245,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 305.12,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46422,US AXILLA LEFT,76882,HCPCS,402,RC,8073874,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 305.12,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46423,US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,402,RC,2425341,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 305.12,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46424,US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,402,RC,2425338,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 305.12,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46425,US AXILLA RIGHT,76882,HCPCS,402,RC,8073877,CDM,,,TC|RT,OUTPATIENT,,, 358.96, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 305.12,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46426,US GROIN LEFT,76882,HCPCS,402,RC,9303962,CDM,,,TC|LT,OUTPATIENT,,, 358.96, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 305.12,,OUTPCT LIMIT, 207.04,OTHER, 133.37, 351.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46427,REPORT US EXTREMITY NONVASCULAR LIMITED RIGHT,76882,HCPCS,999,RC,2425343,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46428,US AXILLA LEFT - REPORT,76882,HCPCS,999,RC,8073876,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46429,US AXILLA RIGHT - REPORT,76882,HCPCS,999,RC,8073879,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46430,US EXTREMITY NONVASCULAR LIMITED BILAT - REPORT,76882,HCPCS,999,RC,3148328,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46431,US UPPER EXT NONVASCULAR LIMITED LEFT - REPORT,76882,HCPCS,999,RC,8243247,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46432,US UPPER EXT NONVASCULAR LIMITED RIGHT - REPORT,76882,HCPCS,999,RC,8243250,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46433,US GROIN LEFT - REPORT,76882,HCPCS,999,RC,9303964,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46434,REPORT US EXTREMITY NONVASCULAR LIMITED LEFT,76882,HCPCS,999,RC,2425340,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46435,US GROIN RIGHT - REPORT,76882,HCPCS,999,RC,9303967,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 189.09,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46436,US GUIDED VASCULAR ACCESS,76937,HCPCS,402,RC,2425350,CDM,,,TC,OUTPATIENT,,, 664.89, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 565.16,,OUTPCT LIMIT, 426.14,OTHER, 285.90, 651.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46437,US GUIDED VASCULAR ACCESS - REPORT,76937,HCPCS,999,RC,2425352,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 220.05,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46438,XR C-ARM FLUORO,77003,HCPCS,320,RC,9287583,CDM,,,TC,OUTPATIENT,,, 424.59, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 360.90,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46439,XR FLUOROSCOPY OVER 1 HOUR EO,77003,HCPCS,320,RC,8073975,CDM,,,TC,OUTPATIENT,,, 424.59, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 360.90,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46440,XR FLUOROSCOPY UNDER 1 HOUR EO,77003,HCPCS,320,RC,8058258,CDM,,,TC,OUTPATIENT,,, 424.59, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 360.90,,OUTPCT LIMIT, 272.12,OTHER, 182.57, 416.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46441,MRI BREAST W/ + W/O CONTRAST RIGHT - REPORT,77048,HCPCS,999,RC,8044398,CDM,,,26|RT,OUTPATIENT,,, 357.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 303.45,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46442,MRI BREAST W/ + W/O CONTRAST LEFT - REPORT,77048,HCPCS,999,RC,8044396,CDM,,,26|LT,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 340.08,OTHER, 187.68, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46443,MRI BREAST W/ + W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627693,CDM,,,26,OUTPATIENT,,, 357.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 303.45,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46444,MRI BREAST W/O CONTRAST BILATERAL - REPORT,77049,HCPCS,999,RC,627705,CDM,,,26,OUTPATIENT,,, 357.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 303.45,,OUTPCT LIMIT, 285.66,OTHER, 157.65, 349.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46445,MG BREAST TOMO 3D DIGITAL DIAG LEFT,77061,HCPCS,401,RC,2425796,CDM,,,TC,OUTPATIENT,,, 291.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 247.35,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46446,MG BREAST TOMO 3D DIGITAL DIAG RIGHT,77061,HCPCS,401,RC,2425799,CDM,,,TC,OUTPATIENT,,, 291.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 247.35,,OUTPCT LIMIT, 186.51,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46447,77062 MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77062,HCPCS,401,RC,9848160,CDM,,,TC,OUTPATIENT,,, 142.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 120.70,,OUTPCT LIMIT, 91.01,OTHER, 61.06, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46448,77062 MG MAMMO SCREENING BILATERAL W/ TOMO,77063,HCPCS,403,RC,9845778,CDM,,,TC,OUTPATIENT,,, 185.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 157.25,,OUTPCT LIMIT, 78.82,OTHER, 21.15, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46449,MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,401,RC,8213736,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 247.35,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46450,MG MAMMO DIGITAL DIAGNOSTIC RIGHT,77065,HCPCS,401,RC,969803,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 247.35,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46451,MG MAMMO DIGITAL DIAGNOSTIC LEFT,77065,HCPCS,401,RC,969801,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 247.35,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46452,MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,401,RC,8213739,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 247.35,,OUTPCT LIMIT, 185.61,OTHER, 125.13, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46453,REPORT MG MAMMO DIAGNOSTIC RIGHT W/ TOMO,77065,HCPCS,999,RC,8213741,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46454,MG MAMMO DIGITAL DIAGNOSTIC LEFT - REPORT,77065,HCPCS,999,RC,675657,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46455,REPORT MG MAMMO DIAGNOSTIC LEFT W/ TOMO,77065,HCPCS,999,RC,8213738,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46456,MG MAMMO DIGITAL DIAGNOSTIC RIGHT - REPORT,77065,HCPCS,999,RC,675659,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 181.00,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46457,MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,401,RC,8213733,CDM,,,TC,OUTPATIENT,,, 490.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 416.50,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46458,MG MAMMO DIGITAL DIAGNOSTIC BILAT,77066,HCPCS,401,RC,969799,CDM,,,TC,OUTPATIENT,,, 409.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 347.65,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46459,MG BREAST TOMO 3D DIGITAL DIAG BILATERAL,77066,HCPCS,401,RC,2425793,CDM,,,TC,OUTPATIENT,,, 490.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 416.50,,OUTPCT LIMIT, 281.03,OTHER, 175.87, 480.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46460,REPORT MG MAMMO DIAGNOSTIC BILATERAL W/ TOMO,77066,HCPCS,999,RC,8213735,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46461,MG MAMMO DIGITAL DIAGNOSTIC BILAT - REPORT,77066,HCPCS,999,RC,675655,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 198.15,OTHER, 99.36, 230.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46462,MG MAMMO SCREENING RIGHT W/ TOMO,77067,HCPCS,403,RC,9164608,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 247.35,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46463,MG MAMMO SCREENING LEFT W/ TOMO,77067,HCPCS,403,RC,9164605,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 247.35,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46464,MG MAMMO DIGITAL SCREENING RIGHT,77067,HCPCS,403,RC,2425805,CDM,,,TC|RT,OUTPATIENT,,, 291.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 247.35,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46465,MG MAMMO DIGITAL SCREENING LEFT,77067,HCPCS,403,RC,2425802,CDM,,,TC|LT,OUTPATIENT,,, 291.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 247.35,,OUTPCT LIMIT, 171.54,OTHER, 81.44, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46466,MG BREAST TOMO 3D DIGITAL SCREENING,77067,HCPCS,403,RC,4645261,CDM,,,TC,OUTPATIENT,,, 600.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 510.00,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46467,MG MAMMO SCREENING BILATERAL W/ TOMO,77067,HCPCS,403,RC,8615799,CDM,,,TC,OUTPATIENT,,, 415.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 352.75,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46468,MG MAMMO DIGITAL SCREENING BILATERAL,77067,HCPCS,403,RC,969805,CDM,,,TC,OUTPATIENT,,, 415.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 352.75,,OUTPCT LIMIT, 235.21,OTHER, 81.44, 588.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46469,MG BREAST TOMO 3D DIGITAL SCREENING - REPORT,77067,HCPCS,999,RC,4645263,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46470,MG MAMMO SCREENING RIGHT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164610,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46471,MG MAMMO SCREENING LEFT W/ TOMO - REPORT,77067,HCPCS,999,RC,9164607,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46472,MG MAMMO DIGITAL SCREENING BILATERAL - REPORT,77067,HCPCS,999,RC,677601,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46473,MG MAMMO DIGITAL SCREENING LEFT - REPORT,77067,HCPCS,999,RC,2425804,CDM,,,26|LT,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46474,MG MAMMO SCREENING BILATERAL W/ TOMO - REPORT,77067,HCPCS,999,RC,8615801,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46475,MG MAMMO DIGITAL SCREENING RIGHT - REPORT,77067,HCPCS,999,RC,2425807,CDM,,,26|RT,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 182.05,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46476,XR BONE AGE STUDIES,77072,HCPCS,320,RC,1170014,CDM,,,TC,OUTPATIENT,,, 171.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 145.35,,OUTPCT LIMIT, 116.40,OTHER, 73.53, 167.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46477,XR BONE AGE STUDIES - REPORT,77072,HCPCS,999,RC,627629,CDM,,,26,OUTPATIENT,,, 42.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 35.70,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46478,XR BONE SURVEY COMPLETE,77075,HCPCS,320,RC,8161610,CDM,,,TC,OUTPATIENT,,, 734.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 624.61,,OUTPCT LIMIT, 414.07,OTHER, 232.03, 720.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46479,BD BONE DENSITY DEXA (G),77080,HCPCS,320,RC,2930314,CDM,,,TC,OUTPATIENT,,, 196.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 166.60,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46480,BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,320,RC,1167839,CDM,,,TC,OUTPATIENT,,, 351.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 298.35,,OUTPCT LIMIT, 158.67,OTHER, 84.28, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46481,BD BONE DENSITY DEXA (G) - REPORT,77080,HCPCS,999,RC,2930316,CDM,,,26,OUTPATIENT,,, 42.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 35.70,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46482,REPORT BD BONE DENSITY DEXA AXIAL SKELETON,77080,HCPCS,999,RC,611591,CDM,,,26,OUTPATIENT,,, 42.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 35.70,,OUTPCT LIMIT, 59.28,OTHER, 18.55, 105.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46483,BD BONE DENSITY DEXA APP SKELETON,77081,HCPCS,320,RC,1167837,CDM,,,TC,OUTPATIENT,,, 296.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 251.60,,OUTPCT LIMIT, 154.63,OTHER, 42.36, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46484,BD BONE DENSITY DEXA VERT FRACTURE ASSMT,77085,HCPCS,351,RC,8044327,CDM,,,TC,OUTPATIENT,,, 351.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 298.35,,OUTPCT LIMIT, 204.30,OTHER, 138.19, 343.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46485,BD BONE DENSITY DEXA VERT FRACTURE ASSMT - REPORT,77085,HCPCS,999,RC,8044329,CDM,,,26,OUTPATIENT,,, 42.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 35.70,,OUTPCT LIMIT, 70.96,OTHER, 18.55, 138.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46486,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI,78012,HCPCS,340,RC,2425944,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1085.31,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46487,NM THYROID UPTAKE SINGLE OR MULTI,78012,HCPCS,340,RC,3630554,CDM,,,TC,OUTPATIENT,,, 1276.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1085.31,,OUTPCT LIMIT, 660.83,OTHER, 156.82, 1251.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46488,NM THYROID UPTAKE SINGLE OR MULTI - REPORT,78012,HCPCS,999,RC,2426013,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46489,NM THYROID IMAGE W/ UPTAKE SNGL OR MULTI - REPORT,78012,HCPCS,999,RC,2425950,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 171.75,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46490,NM THYROID IMAGING,78013,HCPCS,340,RC,2426008,CDM,,,TC,OUTPATIENT,,, 992.56, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 843.68,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46491,NM THYROID SCAN,78013,HCPCS,340,RC,8144336,CDM,,,TC,OUTPATIENT,,, 992.56, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 843.68,,OUTPCT LIMIT, 533.81,OTHER, 206.35, 972.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46492,NM THYROID SCAN - REPORT,78013,HCPCS,999,RC,8144338,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46493,NM THYROID IMAGING - REPORT,78013,HCPCS,999,RC,2426010,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 189.44,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46494,NM THYROID UPTAKE,78014,HCPCS,340,RC,8144339,CDM,,,TC,OUTPATIENT,,, 1395.91, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1186.52,,OUTPCT LIMIT, 757.92,OTHER, 320.35, 1367.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46495,NM THYROID UPTAKE - REPORT,78014,HCPCS,999,RC,8144341,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 230.15,OTHER, 99.36, 320.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46496,NM PARATHYROID IMAGING,78070,HCPCS,340,RC,1169316,CDM,,,TC,OUTPATIENT,,, 1685.39, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1432.58,,OUTPCT LIMIT, 899.81,OTHER, 322.62, 1651.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46497,NM PARATHYROID IMAGING - REPORT,78070,HCPCS,999,RC,631474,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 230.96,OTHER, 99.36, 322.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46498,NM PARATHYROID IMAGING W/ SPECT,78072,HCPCS,340,RC,2425984,CDM,,,TC,OUTPATIENT,,, 1970.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1674.50,,OUTPCT LIMIT, 1092.65,OTHER, 548.80, 1930.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46499,NM PARATHYROID IMAGING W/ SPECT - REPORT,78072,HCPCS,999,RC,2425986,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 311.74,OTHER, 99.36, 548.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46500,NM LIVER/SPLEEN STATIC,78215,HCPCS,340,RC,8073860,CDM,,,TC,OUTPATIENT,,, 1563.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1328.66,,OUTPCT LIMIT, 864.03,OTHER, 423.08, 1531.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46501,NM LIVER/SPLEEN STATIC - REPORT,78215,HCPCS,999,RC,8073862,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46502,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW,78216,HCPCS,340,RC,1169288,CDM,,,TC,OUTPATIENT,,, 500.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 425.00,,OUTPCT LIMIT, 344.89,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46503,NM LIVER/SPLEEN IMAGING W/ VASCULAR FLOW - REPORT,78216,HCPCS,999,RC,631342,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 266.84,OTHER, 99.36, 423.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46504,NM HEPATOBILIARY IMAGING,78226,HCPCS,340,RC,2425954,CDM,,,TC,OUTPATIENT,,, 1500.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1275.00,,OUTPCT LIMIT, 830.31,OTHER, 410.92, 1470.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46505,NM HEPATOBILIARY IMAGING - REPORT,78226,HCPCS,999,RC,2425956,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46506,NM HEPATOBILIARY IMAGING W/ DRUG,78227,HCPCS,340,RC,2425957,CDM,,,TC,OUTPATIENT,,, 2060.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1751.00,,OUTPCT LIMIT, 1103.77,OTHER, 410.92, 2018.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46507,NM HEPATOBILIARY IMAGING W/ DRUG - REPORT,78227,HCPCS,999,RC,2425959,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 262.50,OTHER, 99.36, 410.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46508,NM GASTROESOPHAGEAL REFLUX STUDY,78262,HCPCS,340,RC,1169240,CDM,,,TC,OUTPATIENT,,, 2100.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1785.00,,OUTPCT LIMIT, 1111.16,OTHER, 359.95, 2058.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46509,NM GASTROESOPHAGEAL REFLUX STUDY - REPORT,78262,HCPCS,999,RC,631164,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46510,NM GASTRIC EMPTYING STUDY,78264,HCPCS,340,RC,1169236,CDM,,,TC,OUTPATIENT,,, 1102.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 937.13,,OUTPCT LIMIT, 624.07,OTHER, 359.95, 1080.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46511,NM GASTRIC EMPTYING STUDY - REPORT,78264,HCPCS,999,RC,631162,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 244.29,OTHER, 99.36, 359.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46512,NM BONE IMAGING LIMITED,78300,HCPCS,340,RC,1169176,CDM,,,TC,OUTPATIENT,,, 1201.33, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1021.13,,OUTPCT LIMIT, 672.34,OTHER, 360.01, 1177.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46513,NM BONE IMAGING LIMITED - REPORT,78300,HCPCS,999,RC,627641,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46514,NM BONE IMAGING MULTIPLE AREAS,78305,HCPCS,340,RC,1169178,CDM,,,TC,OUTPATIENT,,, 970.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 824.50,,OUTPCT LIMIT, 559.38,OTHER, 360.01, 950.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46515,NM BONE IMAGING MULTIPLE AREAS - REPORT,78305,HCPCS,999,RC,627643,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46516,NM BONE IMAGING WHOLE BODY,78306,HCPCS,340,RC,1169180,CDM,,,TC,OUTPATIENT,,, 2339.36, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1988.46,,OUTPCT LIMIT, 1228.06,OTHER, 360.01, 2292.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46517,NM BONE IMAGING WHOLE BODY - REPORT,78306,HCPCS,999,RC,627645,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46518,NM BONE THREE PHASE STUDY,78315,HCPCS,340,RC,1169190,CDM,,,TC,OUTPATIENT,,, 2474.51, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2103.33,,OUTPCT LIMIT, 1294.05,OTHER, 360.01, 2425.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46519,NM BONE THREE PHASE STUDY - REPORT,78315,HCPCS,999,RC,627665,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 244.32,OTHER, 99.36, 360.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46520,NM BONE SPECT,78320,HCPCS,340,RC,1169188,CDM,,,TC,OUTPATIENT,,, 1095.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 930.75,,OUTPCT LIMIT, 701.80,OTHER, 470.85, 1073.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46521,NM BONE SPECT - REPORT,78320,HCPCS,999,RC,627657,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 180.04,OTHER, 99.36, 220.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46522,NM CARDIOVASCULAR STRESS TEST EO,78451,HCPCS,340,RC,9078595,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1532.98,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46523,NM CARDIAC MUGA EO,78451,HCPCS,340,RC,8872873,CDM,,,TC,OUTPATIENT,,, 1803.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1532.98,,OUTPCT LIMIT, 1149.19,OTHER, 775.51, 1767.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46524,NM CARDIOVASCULAR STRESS TEST EO - REPORT,78451,HCPCS,999,RC,9078597,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46525,NM CARDIAC MUGA EO - REPORT,78451,HCPCS,999,RC,8872875,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46526,NM MYOCARDIAL SPECT REST AND STRESS,78452,HCPCS,340,RC,2425975,CDM,,,TC,OUTPATIENT,,, 4094.28, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3480.14,,OUTPCT LIMIT, 2267.81,OTHER, 1127.76, 4012.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46527,NM MYOCARDIAL SPECT REST AND STRESS - REPORT,78452,HCPCS,999,RC,2425977,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 518.51,OTHER, 99.36, 1127.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46528,NM CARDIAC MUGA,78472,HCPCS,340,RC,1169208,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1234.29,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46529,NM CARDIAC BLOOD POOL SINGLE REST/STRESS,78472,HCPCS,340,RC,8093231,CDM,,,TC,OUTPATIENT,,, 1452.10, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1234.29,,OUTPCT LIMIT, 815.01,OTHER, 444.92, 1423.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46530,NM CARDIAC BLOOD POOL SINGLE REST/STRESS - REPORT,78472,HCPCS,999,RC,8093233,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46531,NM CARDIAC MUGA - REPORT,78472,HCPCS,999,RC,629625,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 274.64,OTHER, 99.36, 444.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46532,NM LUNG VENTILATION IMAGING,78579,HCPCS,340,RC,2425969,CDM,,,TC,OUTPATIENT,,, 1163.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 989.19,,OUTPCT LIMIT, 635.79,OTHER, 283.54, 1140.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46533,NM LUNG VENTILATION IMAGING - REPORT,78579,HCPCS,999,RC,2425971,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 217.00,OTHER, 99.36, 283.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46534,NM LUNG PERFUSION IMAGING,78580,HCPCS,340,RC,1169328,CDM,,,TC,OUTPATIENT,,, 1868.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1588.51,,OUTPCT LIMIT, 984.09,OTHER, 300.36, 1831.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46535,NM LUNG PERFUSION IMAGING - REPORT,78580,HCPCS,999,RC,631507,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 223.01,OTHER, 99.36, 300.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46536,NM LUNG VENT/PERF IMAGING,78582,HCPCS,340,RC,2425966,CDM,,,TC,OUTPATIENT,,, 1934.32, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1644.17,,OUTPCT LIMIT, 1050.06,OTHER, 443.12, 1895.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46537,NM LUNG VENT/PERF IMAGING - REPORT,78582,HCPCS,999,RC,2425968,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 274.00,OTHER, 99.36, 443.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46538,NM LIVER IMAGING SPECT,78803,HCPCS,340,RC,1169278,CDM,,,TC,OUTPATIENT,,, 1040.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 884.00,,OUTPCT LIMIT, 684.67,OTHER, 447.20, 1019.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46539,NM LIVER IMAGING SPECT - REPORT,78803,HCPCS,999,RC,631310,CDM,,,26,OUTPATIENT,,, 225.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.25,,OUTPCT LIMIT, 380.97,OTHER, 99.36, 742.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46540,PET CT SKULL BASE TO MIDTHIGH,78815,HCPCS,404,RC,1169558,CDM,,,TC,OUTPATIENT,,, 4764.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 4049.40,,OUTPCT LIMIT, 2685.69,OTHER, 1509.32, 4668.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46541,PET CT SKULL BASE TO MIDTHIGH - REPORT,78815,HCPCS,999,RC,675764,CDM,,,26,OUTPATIENT,,, 400.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 340.00,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46542,PET CT WHOLE BODY,78816,HCPCS,404,RC,1169560,CDM,,,TC,OUTPATIENT,,, 4934.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 4193.90,,OUTPCT LIMIT, 2768.70,OTHER, 1509.32, 4835.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46543,PET CT WHOLE BODY - REPORT,78816,HCPCS,999,RC,675766,CDM,,,26,OUTPATIENT,,, 400.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 340.00,,OUTPCT LIMIT, 744.80,OTHER, 176.64, 1509.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46544,BASIC METABOLIC PANEL ISTAT,80047,HCPCS,300,RC,8064883,CDM,,,,OUTPATIENT,,, 60.59, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 51.50,,OUTPCT LIMIT, 34.30,OTHER, 19.78, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46545,BASIC METABOLIC PANEL,80048,HCPCS,300,RC,633628,CDM,,,,OUTPATIENT,,, 60.59, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 51.50,,OUTPCT LIMIT, 32.49,OTHER, 12.18, 59.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46546,GENERAL HEALTH PANEL,80050,HCPCS,300,RC,8327768,CDM,,,,OUTPATIENT,,, 622.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 528.70,,OUTPCT LIMIT, 398.65,OTHER, 267.46, 609.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46547,LYTES,80051,HCPCS,300,RC,633610,CDM,,,,OUTPATIENT,,, 139.85, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 118.87,,OUTPCT LIMIT, 70.69,OTHER, 10.09, 137.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46548,CMP,80053,HCPCS,300,RC,633709,CDM,,,,OUTPATIENT,,, 242.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 206.34,,OUTPCT LIMIT, 122.16,OTHER, 15.20, 237.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46549,LIPID PNL,80061,HCPCS,300,RC,633777,CDM,,,,OUTPATIENT,,, 190.47, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 161.90,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46550,LIPID PANEL TC,80061,HCPCS,300,RC,9300131,CDM,,,,OUTPATIENT,,, 190.47, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 161.90,,OUTPCT LIMIT, 97.60,OTHER, 19.28, 186.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46551,RENAL PANEL (10) LC,80069,HCPCS,300,RC,8899874,CDM,,,,OUTPATIENT,,, 165.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 140.25,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46552,RENAL PNL,80069,HCPCS,300,RC,1634883,CDM,,,,OUTPATIENT,,, 165.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 140.25,,OUTPCT LIMIT, 83.55,OTHER, 12.50, 161.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46553,HEPATITIS PANEL ACUTE TC,80074,HCPCS,300,RC,9285850,CDM,,,,OUTPATIENT,,, 285.72, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 242.86,,OUTPCT LIMIT, 155.85,OTHER, 68.59, 280.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46554,HEP FNCT PNL,80076,HCPCS,300,RC,633744,CDM,,,,OUTPATIENT,,, 156.01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 132.61,,OUTPCT LIMIT, 78.98,OTHER, 11.76, 152.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46555,ACETAMINOPHEN LVL,80143,HCPCS,300,RC,1503764,CDM,,,,OUTPATIENT,,, 131.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 111.35,,OUTPCT LIMIT, 69.30,OTHER, 22.37, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46556,ADALIMUMAB ACTIVITY AND NEUTRALIZING ANTIBODY TC,80145,HCPCS,300,RC,9250724,CDM,,,,OUTPATIENT,,, 447.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 379.95,,OUTPCT LIMIT, 229.30,OTHER, 46.28, 438.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46557,CARBAMAZEPINE (TEGRETOL XR) TC,80156,HCPCS,300,RC,9258710,CDM,,,,OUTPATIENT,,, 176.26, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 149.82,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46558,CARBAMAZEPINE EPOXIDE AND TOTAL TC,80156,HCPCS,300,RC,9258711,CDM,,,,OUTPATIENT,,, 167.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 142.46,,OUTPCT LIMIT, 88.95,OTHER, 20.98, 172.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46559,DIGOXIN (LANOXIN) TC,80162,HCPCS,300,RC,9273794,CDM,,,,OUTPATIENT,,, 100.01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 85.01,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46560,DIGOXIN LEVEL,80162,HCPCS,300,RC,1628891,CDM,,,,OUTPATIENT,,, 100.01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 85.01,,OUTPCT LIMIT, 53.39,OTHER, 19.13, 98.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46561,VALPROIC ACID LEVEL,80164,HCPCS,300,RC,3170351,CDM,,,,OUTPATIENT,,, 154.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 131.47,,OUTPCT LIMIT, 80.17,OTHER, 19.50, 151.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46562,GABAPENTIN (NEURONTIN) TC,80171,HCPCS,300,RC,9282553,CDM,,,,OUTPATIENT,,, 96.62, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 82.13,,OUTPCT LIMIT, 54.61,OTHER, 31.20, 94.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46563,LAMOTRIGINE SERUM TC,80175,HCPCS,300,RC,9296805,CDM,,,,OUTPATIENT,,, 154.58, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 131.39,,OUTPCT LIMIT, 80.03,OTHER, 19.08, 151.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46564,KEPPRA (LEVETIRACETAM) TC,80177,HCPCS,300,RC,9296778,CDM,,,,OUTPATIENT,,, 152.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 129.91,,OUTPCT LIMIT, 79.17,OTHER, 19.08, 149.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46565,LITHIUM LEVEL,80178,HCPCS,300,RC,2046348,CDM,,,,OUTPATIENT,,, 126.32, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 107.37,,OUTPCT LIMIT, 63.95,OTHER, 9.52, 123.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46566,SALICYLATE,80179,HCPCS,300,RC,1503768,CDM,,,,OUTPATIENT,,, 47.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 39.95,,OUTPCT LIMIT, 28.28,OTHER, 20.21, 46.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46567,OXCARBAZEPINE OR ESLICARBAZEPINE METABOLITE (MHD) TC,80183,HCPCS,300,RC,9319384,CDM,,,,OUTPATIENT,,, 162.08, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 137.77,,OUTPCT LIMIT, 83.69,OTHER, 19.08, 158.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46568,PHENOBARBITAL TC,80184,HCPCS,300,RC,9326295,CDM,,,,OUTPATIENT,,, 98.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 83.94,,OUTPCT LIMIT, 53.47,OTHER, 22.03, 96.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46569,PHENYTOIN LEVEL TOTAL,80185,HCPCS,300,RC,633801,CDM,,,,OUTPATIENT,,, 154.14, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 131.02,,OUTPCT LIMIT, 79.81,OTHER, 19.08, 151.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46570,SIROLIMUS (RAPAMUNE RAPAMYCIN) TC,80195,HCPCS,300,RC,9332213,CDM,,,,OUTPATIENT,,, 81.78, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 69.51,,OUTPCT LIMIT, 44.64,OTHER, 19.78, 80.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46571,TACROLIMUS TC,80197,HCPCS,300,RC,9332257,CDM,,,,OUTPATIENT,,, 289.17, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 245.79,,OUTPCT LIMIT, 145.91,OTHER, 19.78, 283.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46572,THEOPHYLLINE TC,80198,HCPCS,300,RC,9333749,CDM,,,,OUTPATIENT,,, 122.70, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 104.30,,OUTPCT LIMIT, 64.76,OTHER, 20.36, 120.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46573,TOPIRAMATE (TOPAMAX) TC,80201,HCPCS,300,RC,9333752,CDM,,,,OUTPATIENT,,, 240.12, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 204.10,,OUTPCT LIMIT, 121.34,OTHER, 17.16, 235.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46574,VANCOMYCIN LEVEL,80202,HCPCS,300,RC,1634895,CDM,,,,OUTPATIENT,,, 164.06, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 139.45,,OUTPCT LIMIT, 84.76,OTHER, 19.50, 160.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46575,LACOSAMIDE SERUM OR PLASMA TC,80235,HCPCS,300,RC,9296794,CDM,,,,OUTPATIENT,,, 259.97, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 220.97,,OUTPCT LIMIT, 134.69,OTHER, 32.53, 254.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46576,DEXAMETHASONE SERUM OR PLASMA BY LC-MS/MS TC,80299,HCPCS,300,RC,9273787,CDM,,,,OUTPATIENT,,, 173.08, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 147.12,,OUTPCT LIMIT, 90.91,OTHER, 26.84, 169.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46577,U DRUG SCR,80305,HCPCS,300,RC,3454403,CDM,,,,OUTPATIENT,,, 190.34, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 161.79,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46578,BILL ONLY EMP DRG SCRN COLLECTION,80305,HCPCS,300,RC,9576192,CDM,,,,OUTPATIENT,,, 25.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 21.25,,OUTPCT LIMIT, 56.90,OTHER, 10.75, 186.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46579,URINE DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198041,CDM,,,,OUTPATIENT,,, 40.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 34.00,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46580,DRUG SCREEN CLINIC POC (RE),80305,HCPCS,521,RC,8198021,CDM,,,,OUTPATIENT,,, 40.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 34.00,,OUTPCT LIMIT, 23.85,OTHER, 17.20, 39.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46581,ALDOSTERONE TC,80320,HCPCS,300,RC,9249756,CDM,,,,OUTPATIENT,,, 261.88, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 222.60,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46582,ETHANOL BLOOD,80320,HCPCS,300,RC,1503765,CDM,,,,OUTPATIENT,,, 295.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 250.75,,OUTPCT LIMIT, 178.46,OTHER, 112.61, 289.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46583,PHOSPHATIDYLETHANOL TC,80321,HCPCS,300,RC,9321222,CDM,,,,OUTPATIENT,,, 169.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 143.65,,OUTPCT LIMIT, 108.31,OTHER, 72.67, 165.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46584,NICOTINE AND COTININE METABOLITE TC,80323,HCPCS,300,RC,9313594,CDM,,,,OUTPATIENT,,, 150.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 127.50,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46585,AMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80324,HCPCS,300,RC,9294968,CDM,,,,OUTPATIENT,,, 76.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 64.60,,OUTPCT LIMIT, 48.71,OTHER, 32.68, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46586,CALCIUM URINE RANDOM TC,80337,HCPCS,300,RC,9338610,CDM,,,,OUTPATIENT,,, 280.77, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 238.65,,OUTPCT LIMIT, 179.95,OTHER, 120.73, 275.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46587,BARBITURATES QNT TC,80345,HCPCS,300,RC,9249391,CDM,,,,OUTPATIENT,,, 178.85, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 152.02,,OUTPCT LIMIT, 114.63,OTHER, 76.91, 175.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46588,BENZODIAZEPINES MEDICAL URINE TC,80346,HCPCS,300,RC,9294971,CDM,,,,OUTPATIENT,,, 40.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 34.71,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46589,THCA MEDICAL URINE TC,80349,HCPCS,300,RC,9311073,CDM,,,,OUTPATIENT,,, 75.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 63.75,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46590,COCAINE MEDICAL URINE TC,80353,HCPCS,300,RC,9294969,CDM,,,,OUTPATIENT,,, 40.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 34.71,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46591,COCAINE SCREEN URINE TC,80353,HCPCS,300,RC,9338625,CDM,,,,OUTPATIENT,,, 40.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 34.71,,OUTPCT LIMIT, 26.17,OTHER, 17.56, 40.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46592,METHADONE AND METABOLITE (EDDP) URINE LCMSMS TC,80358,HCPCS,300,RC,9310648,CDM,,,,OUTPATIENT,,, 141.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 119.85,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46593,METHYLENEDIOXYAMPHETAMINES QUANTITATIVE IN URINE BY LCMS TC,80359,HCPCS,300,RC,9310638,CDM,,,,OUTPATIENT,,, 105.89, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 90.01,,OUTPCT LIMIT, 67.87,OTHER, 45.53, 103.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46594,OPIATES CONFIRMATION URINE LC,80361,HCPCS,300,RC,8739226,CDM,,,,OUTPATIENT,,, 159.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 135.15,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46595,OPIATES CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80361,HCPCS,300,RC,9250802,CDM,,,,OUTPATIENT,,, 159.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 135.15,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46596,OPIATES MEDICAL CONFIRMATION HPLC-MS/MS URINE TC,80361,HCPCS,300,RC,9311076,CDM,,,,OUTPATIENT,,, 159.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 135.15,,OUTPCT LIMIT, 101.91,OTHER, 68.37, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46597,TRAMADOL AND METABOLITE URINE LCMSMS TC,80373,HCPCS,300,RC,9312649,CDM,,,,OUTPATIENT,,, 135.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 114.75,,OUTPCT LIMIT, 86.52,OTHER, 58.05, 132.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46598,BUPRENORPHINE AND METABOLITES QNT. CONFIRMATION/QUANTITATION (SERUM/PLASMA) TC,80375,HCPCS,300,RC,9249447,CDM,,,,OUTPATIENT,,, 86.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.10,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46599,DRUG SCREEN WITH REFLEX TO CONFIRMATION/QUANTITATIONSERUM TC,80375,HCPCS,300,RC,9275073,CDM,,,,OUTPATIENT,,, 291.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 247.35,,OUTPCT LIMIT, 120.81,OTHER, 36.98, 285.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46600,UA W MICRO,81001,HCPCS,300,RC,4123061,CDM,,,,OUTPATIENT,,, 69.21, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 58.83,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46601,UA MICRO,81001,HCPCS,300,RC,633864,CDM,,,,OUTPATIENT,,, 69.21, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 58.83,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46602,.URINALYSIS MICROSCOPIC TC,81001,HCPCS,300,RC,9561668,CDM,,,,OUTPATIENT,,, 69.21, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 58.83,,OUTPCT LIMIT, 34.88,OTHER, 4.56, 67.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46603,UA DIP ONLY,81003,HCPCS,300,RC,8165994,CDM,,,,OUTPATIENT,,, 41.29, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 35.10,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46604,UA W MICRO IF IND,81003,HCPCS,300,RC,1148022,CDM,,,,OUTPATIENT,,, 41.29, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 35.10,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46605,UA W MICRO IF IND AND CULT IF IND,81003,HCPCS,300,RC,8276103,CDM,,,,OUTPATIENT,,, 41.29, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 35.10,,OUTPCT LIMIT, 20.93,OTHER, 3.24, 40.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46606,URINE DIPSTICK CLINIC POC (RE),81003,HCPCS,521,RC,8198040,CDM,,,,OUTPATIENT,,, 13.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 11.05,,OUTPCT LIMIT, 7.12,OTHER, 3.24, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46607,BILL ONLY ICTO TEST,81005,HCPCS,300,RC,9576477,CDM,,,,OUTPATIENT,,, 15.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 12.75,,OUTPCT LIMIT, 8.07,OTHER, 3.12, 14.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46608,U B-HCG QL,81025,HCPCS,300,RC,633664,CDM,,,,OUTPATIENT,,, 63.30, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 53.81,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46609,B-HCG QL,81025,HCPCS,300,RC,633663,CDM,,,,OUTPATIENT,,, 63.30, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 53.81,,OUTPCT LIMIT, 33.86,OTHER, 12.40, 62.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46610,URINE PREGNANCY TEST POC (RE),81025,HCPCS,521,RC,9091465,CDM,,,,OUTPATIENT,,, 149.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 126.65,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46611,URINE PREGNANCY TEST CLINIC POC (RE),81025,HCPCS,521,RC,8198042,CDM,,,,OUTPATIENT,,, 149.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 126.65,,OUTPCT LIMIT, 75.71,OTHER, 12.40, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46612,FACTOR V ACTIVITY TC,81241,HCPCS,300,RC,9275909,CDM,,,,OUTPATIENT,,, 246.64, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 209.64,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46613,FACTOR V LEIDEN PCR TC,81241,HCPCS,300,RC,9279290,CDM,,,,OUTPATIENT,,, 246.64, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 209.64,,OUTPCT LIMIT, 145.60,OTHER, 105.66, 241.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46614,HEMOCHROMATOSIS BY PCR TC,81256,HCPCS,300,RC,9282651,CDM,,,,OUTPATIENT,,, 492.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 418.20,,OUTPCT LIMIT, 262.66,OTHER, 94.12, 482.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46615,JAK2(V617F) TC,81270,HCPCS,310,RC,9312523,CDM,,,,OUTPATIENT,,, 814.14, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 692.02,,OUTPCT LIMIT, 428.98,OTHER, 131.99, 797.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46616,MATERNAL SERUM 1SCR TC,81508,HCPCS,300,RC,9312558,CDM,,,,OUTPATIENT,,, 202.34, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 171.99,,OUTPCT LIMIT, 129.68,OTHER, 87.01, 198.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46617,MATERNAL SERUM AFP TC,81511,HCPCS,310,RC,9312564,CDM,,,,OUTPATIENT,,, 382.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 324.70,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46618,MATERNAL SERUM QUAD,81511,HCPCS,310,RC,9884935,CDM,,,,OUTPATIENT,,, 382.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 324.70,,OUTPCT LIMIT, 244.83,OTHER, 164.26, 374.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46619,U KETONES,82009,HCPCS,300,RC,4240803,CDM,,,,OUTPATIENT,,, 105.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.82,,OUTPCT LIMIT, 53.15,OTHER, 6.50, 103.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46620,ACETONE,82010,HCPCS,300,RC,3454315,CDM,,,,OUTPATIENT,,, 73.94, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 62.85,,OUTPCT LIMIT, 38.90,OTHER, 11.76, 72.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46621,ADRENOCORTICOTROPIC HORMONE (ACTH) TC,82024,HCPCS,300,RC,9250739,CDM,,,,OUTPATIENT,,, 273.58, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 232.54,,OUTPCT LIMIT, 146.83,OTHER, 55.61, 268.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46622,ALBUMIN LEVEL,82040,HCPCS,300,RC,1620877,CDM,,,,OUTPATIENT,,, 37.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 32.09,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46623,ALBUMIN TC,82040,HCPCS,300,RC,9257319,CDM,,,,OUTPATIENT,,, 37.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 32.09,,OUTPCT LIMIT, 20.13,OTHER, 7.13, 37.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46624,ALBUMIN FLUID TC,82042,HCPCS,300,RC,9279408,CDM,,,,OUTPATIENT,,, 53.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 45.69,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46625,ALBUMIN CSF TC,82042,HCPCS,300,RC,9329298,CDM,,,,OUTPATIENT,,, 53.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 45.69,,OUTPCT LIMIT, 28.92,OTHER, 11.21, 52.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46626,MICROALBUMIN / CREATINE LEVEL URINE,82043,HCPCS,300,RC,8385280,CDM,,,,OUTPATIENT,,, 120.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 102.00,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46627,MICROALBUMIN/CREATININE RATIO URINE,82043,HCPCS,300,RC,8045340,CDM,,,,OUTPATIENT,,, 120.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 102.00,,OUTPCT LIMIT, 60.58,OTHER, 8.33, 117.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46628,ALDOLASE TC,82085,HCPCS,300,RC,9250754,CDM,,,,OUTPATIENT,,, 97.37, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 82.76,,OUTPCT LIMIT, 50.88,OTHER, 13.98, 95.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46629,ALPHA-1-ANTITRYPSIN QUANTITATIVE TC,82103,HCPCS,300,RC,9250668,CDM,,,,OUTPATIENT,,, 136.09, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 115.68,,OUTPCT LIMIT, 71.06,OTHER, 19.36, 133.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46630,ALPHA-1-ANTITRYPSIN QUANTITATIVE AND PHENOTYPE TC,82104,HCPCS,300,RC,9249490,CDM,,,,OUTPATIENT,,, 214.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 182.61,,OUTPCT LIMIT, 109.86,OTHER, 20.82, 210.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46631,ALPHA FETOPROTEIN TUMOR MARKER TC,82105,HCPCS,300,RC,9250748,CDM,,,,OUTPATIENT,,, 152.39, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 129.53,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46632,ALPHA FETOPROTEIN TUMOR MARKER,82105,HCPCS,300,RC,633643,CDM,,,,OUTPATIENT,,, 152.39, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 129.53,,OUTPCT LIMIT, 80.16,OTHER, 24.14, 149.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46633,AMMONIA LEVEL,82140,HCPCS,300,RC,1628880,CDM,,,,OUTPATIENT,,, 119.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 101.15,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46634,AMMONIA TC,82140,HCPCS,300,RC,9319367,CDM,,,,OUTPATIENT,,, 119.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 101.15,,OUTPCT LIMIT, 63.10,OTHER, 20.98, 116.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46635,AMYLASE LEVEL,82150,HCPCS,300,RC,631567,CDM,,,,OUTPATIENT,,, 99.46, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 84.54,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46636,AMYLASE TC,82150,HCPCS,300,RC,9255590,CDM,,,,OUTPATIENT,,, 99.46, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 84.54,,OUTPCT LIMIT, 50.79,OTHER, 9.34, 97.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46637,ANDROSTENEDIONE TC,82157,HCPCS,300,RC,9251837,CDM,,,,OUTPATIENT,,, 185.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 157.25,,OUTPCT LIMIT, 100.38,OTHER, 42.16, 181.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46638,ANTI MULLERIAN HORM TC,82166,HCPCS,300,RC,9251836,CDM,,,,OUTPATIENT,,, 227.09, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 193.03,,OUTPCT LIMIT, 121.92,OTHER, 46.34, 222.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46639,APOLIPOPROTEIN B TC,82172,HCPCS,300,RC,9255008,CDM,,,,OUTPATIENT,,, 88.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 74.80,,OUTPCT LIMIT, 50.20,OTHER, 30.37, 86.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46640,WHOLE BLOOD ARSENIC TC,82175,HCPCS,300,RC,9348397,CDM,,,,OUTPATIENT,,, 224.88, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.15,,OUTPCT LIMIT, 116.31,OTHER, 27.31, 220.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46641,VITAMIN C TC,82180,HCPCS,300,RC,9338785,CDM,,,,OUTPATIENT,,, 95.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 80.75,,OUTPCT LIMIT, 49.78,OTHER, 14.24, 93.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46642,BETA-2 MICROGLOBULIN TC,82232,HCPCS,300,RC,9256485,CDM,,,,OUTPATIENT,,, 118.56, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 100.78,,OUTPCT LIMIT, 63.44,OTHER, 23.30, 116.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46643,NEO BILI,82247,HCPCS,300,RC,8273972,CDM,,,,OUTPATIENT,,, 70.94, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 60.30,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46644,BILIRUBIN TOTAL,82247,HCPCS,300,RC,633672,CDM,,,,OUTPATIENT,,, 70.94, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 60.30,,OUTPCT LIMIT, 36.36,OTHER, 7.22, 69.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46645,BILIRUBIN DIRECT,82248,HCPCS,300,RC,4240528,CDM,,,,OUTPATIENT,,, 64.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 54.57,,OUTPCT LIMIT, 33.07,OTHER, 7.22, 62.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46646,FECAL OCCULT BLOOD IMMUNOASSAY TC,82270,HCPCS,300,RC,9282528,CDM,,,,OUTPATIENT,,, 36.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 31.03,,OUTPCT LIMIT, 19.33,OTHER, 6.31, 35.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46647,GUAIAC GAST,82271,HCPCS,300,RC,4123208,CDM,,,,OUTPATIENT,,, 65.17, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 55.39,,OUTPCT LIMIT, 33.34,OTHER, 6.38, 63.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46648,OCCULT BLOOD STOOL SCREEN,82274,HCPCS,300,RC,8045350,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 56.73,OTHER, 22.92, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46649,VITAMIN D 25-OH BY IMMUNOASSAY TC,82306,HCPCS,300,RC,9338781,CDM,,,,OUTPATIENT,,, 233.44, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 198.42,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46650,VIT. DD2D3 25-OH TC,82306,HCPCS,300,RC,9338783,CDM,,,,OUTPATIENT,,, 249.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 211.65,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46651,VITAMIN D 25 HYDROXY LEVEL,82306,HCPCS,300,RC,4240407,CDM,,,,OUTPATIENT,,, 233.44, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 198.42,,OUTPCT LIMIT, 126.67,OTHER, 42.62, 244.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46652,CALCITONIN TC,82308,HCPCS,300,RC,9258709,CDM,,,,OUTPATIENT,,, 234.42, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 199.26,,OUTPCT LIMIT, 123.66,OTHER, 38.58, 229.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46653,CALCIUM LEVEL,82310,HCPCS,300,RC,1635552,CDM,,,,OUTPATIENT,,, 66.17, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.24,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46654,CALCIUM LEVEL TOTAL,82310,HCPCS,300,RC,1628887,CDM,,,,OUTPATIENT,,, 66.17, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.24,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46655,CALCIUM TC,82310,HCPCS,300,RC,9258426,CDM,,,,OUTPATIENT,,, 66.17, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.24,,OUTPCT LIMIT, 34.08,OTHER, 7.43, 64.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46656,CALCIUM IONIZED TC,82330,HCPCS,300,RC,9258708,CDM,,,,OUTPATIENT,,, 132.19, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 112.36,,OUTPCT LIMIT, 69.24,OTHER, 19.70, 129.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46657,CALCIUM URINE 24 HOUR TC,82340,HCPCS,300,RC,9338286,CDM,,,,OUTPATIENT,,, 98.09, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 83.38,,OUTPCT LIMIT, 49.97,OTHER, 8.69, 96.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46658,CALCULI RISK ASSESSMENT URINE TC,82365,HCPCS,300,RC,9338568,CDM,,,,OUTPATIENT,,, 82.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 69.70,,OUTPCT LIMIT, 44.47,OTHER, 18.58, 80.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46659,CARBON MONOXIDE TC,82375,HCPCS,300,RC,9321215,CDM,,,,OUTPATIENT,,, 124.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 106.04,,OUTPCT LIMIT, 65.14,OTHER, 17.74, 122.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46660,CARCINOEMBRYONIC ANTIGEN TC,82378,HCPCS,300,RC,9261096,CDM,,,,OUTPATIENT,,, 165.36, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 140.56,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46661,CARCINOEMBRYONIC ANTIGEN,82378,HCPCS,300,RC,633697,CDM,,,,OUTPATIENT,,, 165.36, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 140.56,,OUTPCT LIMIT, 87.25,OTHER, 27.30, 162.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46662,CARNITINE FREE AND TOTAL TC,82379,HCPCS,300,RC,9258720,CDM,,,,OUTPATIENT,,, 109.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 92.65,,OUTPCT LIMIT, 59.01,OTHER, 24.29, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46663,CATECHOLAMINES PLASMA TC,82384,HCPCS,300,RC,9319391,CDM,,,,OUTPATIENT,,, 243.10, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 206.64,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46664,CATECHOLAMINES FREE FRACTIONATED URINE 24 HOUR TC,82384,HCPCS,300,RC,9336519,CDM,,,,OUTPATIENT,,, 245.42, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 208.61,,OUTPCT LIMIT, 127.93,OTHER, 36.36, 240.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46665,CERULOPLASMIN TC,82390,HCPCS,300,RC,9256005,CDM,,,,OUTPATIENT,,, 108.07, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 91.86,,OUTPCT LIMIT, 56.46,OTHER, 15.47, 105.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46666,CHLORIDE URINE RANDOM TC,82436,HCPCS,300,RC,9338612,CDM,,,,OUTPATIENT,,, 24.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 20.40,,OUTPCT LIMIT, 13.69,OTHER, 8.28, 23.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46667,COPPER WHOLE BLOOD TC,82525,HCPCS,300,RC,9273782,CDM,,,,OUTPATIENT,,, 142.24, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 120.90,,OUTPCT LIMIT, 73.71,OTHER, 17.87, 139.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46668,CORTISOL FREE TC,82530,HCPCS,300,RC,9271114,CDM,,,,OUTPATIENT,,, 167.93, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 142.74,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46669,CORTISOL FREE 24 HR URINE SF,82530,HCPCS,300,RC,8905745,CDM,,,,OUTPATIENT,,, 167.93, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 142.74,,OUTPCT LIMIT, 87.73,OTHER, 24.06, 164.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46670,CORTISOL TOTAL A.M. SF,82533,HCPCS,300,RC,8905577,CDM,,,,OUTPATIENT,,, 124.35, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 105.70,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46671,CORTISOL TC,82533,HCPCS,300,RC,9272484,CDM,,,,OUTPATIENT,,, 124.35, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 105.70,,OUTPCT LIMIT, 66.31,OTHER, 23.47, 121.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46672,DIHYDROTESTOSTERONE (5-A-DIHYDROTESTOSTERONE) TC,82542,HCPCS,300,RC,9275064,CDM,,,,OUTPATIENT,,, 372.56, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 316.68,,OUTPCT LIMIT, 190.19,OTHER, 34.69, 365.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46673,PARATHYROID HORMONE - RELATED PEPTIDE (PTHRP) TC,82542,HCPCS,310,RC,9321427,CDM,,,,OUTPATIENT,,, 421.36, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 358.16,,OUTPCT LIMIT, 214.01,OTHER, 34.69, 412.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46674,CREATINE KINASE (IH),82550,HCPCS,300,RC,633712,CDM,,,,OUTPATIENT,,, 92.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 78.78,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46675,CPK (CREATINE KINASE) TOTAL TC,82550,HCPCS,300,RC,9272426,CDM,,,,OUTPATIENT,,, 92.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 78.78,,OUTPCT LIMIT, 47.49,OTHER, 9.37, 90.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46676,CPK (CREATINE KINASE) ISOENZYMES TC,82552,HCPCS,300,RC,9272428,CDM,,,,OUTPATIENT,,, 76.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 64.60,,OUTPCT LIMIT, 41.70,OTHER, 19.28, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46677,CKMB,82553,HCPCS,300,RC,8059241,CDM,,,,OUTPATIENT,,, 114.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 97.07,,OUTPCT LIMIT, 59.73,OTHER, 16.63, 111.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46678,CREATININE TC,82565,HCPCS,300,RC,9271452,CDM,,,,OUTPATIENT,,, 61.17, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 51.99,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46679,CREATININE,82565,HCPCS,300,RC,8045641,CDM,,,,OUTPATIENT,,, 61.17, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 51.99,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46680,CREATININE,82565,HCPCS,300,RC,3454470,CDM,,,,OUTPATIENT,,, 61.17, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 51.99,,OUTPCT LIMIT, 31.62,OTHER, 7.37, 59.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46681,CREATININE URINE 24 HOUR TC,82570,HCPCS,300,RC,9338297,CDM,,,,OUTPATIENT,,, 76.46, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 64.99,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46682,UR CREATININE TC,82570,HCPCS,300,RC,9353892,CDM,,,,OUTPATIENT,,, 76.46, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 64.99,,OUTPCT LIMIT, 39.11,OTHER, 7.46, 74.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46683,ABG,82575,HCPCS,300,RC,4185532,CDM,,,,OUTPATIENT,,, 184.77, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 157.05,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46684,CREATININE CLEARANCE TC,82575,HCPCS,300,RC,9271451,CDM,,,,OUTPATIENT,,, 184.77, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 157.05,,OUTPCT LIMIT, 93.47,OTHER, 13.62, 181.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46685,CRYOFIBRINOGEN TC,82585,HCPCS,300,RC,9271978,CDM,,,,OUTPATIENT,,, 84.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 71.40,,OUTPCT LIMIT, 45.06,OTHER, 16.97, 82.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46686,CRYOGLOBULIN SCREEN TC,82595,HCPCS,300,RC,9271979,CDM,,,,OUTPATIENT,,, 151.53, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 128.80,,OUTPCT LIMIT, 76.21,OTHER, 9.31, 148.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46687,VITAMIN B12 LEVEL,82607,HCPCS,300,RC,633871,CDM,,,,OUTPATIENT,,, 137.33, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 116.73,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46688,VITAMIN B12 TC,82607,HCPCS,300,RC,9338780,CDM,,,,OUTPATIENT,,, 137.33, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 116.73,,OUTPCT LIMIT, 72.23,OTHER, 21.72, 134.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46689,CYSTATIN C SERUM TC,82610,HCPCS,300,RC,9275051,CDM,,,,OUTPATIENT,,, 141.33, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 120.13,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46690,.CYSTATIN C REFLEX TC,82610,HCPCS,300,RC,9250806,CDM,,,,OUTPATIENT,,, 141.33, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 120.13,,OUTPCT LIMIT, 75.36,OTHER, 26.66, 138.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46691,DHEA (DEHYDROEPIANDROSTERONE) SULFATE TC,82626,HCPCS,300,RC,9275063,CDM,,,,OUTPATIENT,,, 243.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 206.72,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46692,DEHYDROEPIANDROSTERONE SERUM OR PLASMA TC,82626,HCPCS,300,RC,9275056,CDM,,,,OUTPATIENT,,, 243.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 206.72,,OUTPCT LIMIT, 127.42,OTHER, 36.38, 238.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46693,ERYTHROPOIETIN TC,82668,HCPCS,300,RC,9279275,CDM,,,,OUTPATIENT,,, 179.04, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 152.18,,OUTPCT LIMIT, 93.87,OTHER, 27.06, 175.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46694,ESTRADIOL LEVEL,82670,HCPCS,300,RC,3170319,CDM,,,,OUTPATIENT,,, 257.84, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 219.16,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46695,ESTRADIOL BY TMS TC,82670,HCPCS,300,RC,9275891,CDM,,,,OUTPATIENT,,, 257.84, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 219.16,,OUTPCT LIMIT, 135.49,OTHER, 40.24, 252.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46696,ESTROGENSFRACTION TC,82671,HCPCS,300,RC,9275900,CDM,,,,OUTPATIENT,,, 149.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 126.65,,OUTPCT LIMIT, 83.83,OTHER, 46.51, 146.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46697,ESTRIOL TC,82677,HCPCS,300,RC,9275893,CDM,,,,OUTPATIENT,,, 134.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 113.90,,OUTPCT LIMIT, 73.72,OTHER, 34.82, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46698,ESTRONE BY TMS TC,82679,HCPCS,300,RC,9275904,CDM,,,,OUTPATIENT,,, 137.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 116.45,,OUTPCT LIMIT, 75.45,OTHER, 35.93, 134.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46699,ESTRADIOL RAPID IVF ONLY TC,82681,HCPCS,300,RC,9321438,CDM,,,,OUTPATIENT,,, 232.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 197.84,,OUTPCT LIMIT, 121.64,OTHER, 33.53, 228.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46700,FAT FECAL QUALITATIVE TC,82705,HCPCS,300,RC,9275930,CDM,,,,OUTPATIENT,,, 138.06, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 117.35,,OUTPCT LIMIT, 69.17,OTHER, 7.34, 135.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46701,FAT FECAL QUANTITATIVE 24-HOUR COLLECTION TC,82710,HCPCS,300,RC,9279318,CDM,,,,OUTPATIENT,,, 243.51, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 206.98,,OUTPCT LIMIT, 124.67,OTHER, 24.19, 238.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46702,FERRITIN,82728,HCPCS,300,RC,1628893,CDM,,,,OUTPATIENT,,, 147.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 124.95,,OUTPCT LIMIT, 76.46,OTHER, 19.63, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46703,FOLATE LEVEL,82746,HCPCS,300,RC,1628894,CDM,,,,OUTPATIENT,,, 136.06, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 115.65,,OUTPCT LIMIT, 71.48,OTHER, 21.17, 133.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46704,CELIAC DISEASE PANEL WITH REFLEX TC,82784,HCPCS,300,RC,9261097,CDM,,,,OUTPATIENT,,, 423.76, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 360.20,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46705,IGM (IMMUNOGLOBULIN M) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288583,CDM,,,,OUTPATIENT,,, 155.01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 131.76,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46706,IG (IMMUNOGLOBULINS G M AND A) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9288614,CDM,,,,OUTPATIENT,,, 105.76, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.90,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46707,IGA TC,82784,HCPCS,300,RC,9261217,CDM,,,,OUTPATIENT,,, 105.76, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.90,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46708,IGG (IMMUNOGLOBULIN G) SERUM QUANTITATIVE TC,82784,HCPCS,300,RC,9292042,CDM,,,,OUTPATIENT,,, 105.76, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.90,,OUTPCT LIMIT, 90.70,OTHER, 13.39, 415.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46709,IGE TOTAL TC,82785,HCPCS,300,RC,9288585,CDM,,,,OUTPATIENT,,, 121.47, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 103.25,,OUTPCT LIMIT, 64.96,OTHER, 23.70, 119.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46710,IGG SUBCLASSES TC,82787,HCPCS,300,RC,9288582,CDM,,,,OUTPATIENT,,, 66.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.10,,OUTPCT LIMIT, 34.98,OTHER, 11.54, 64.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46711,BLOOD GAS ARTERIAL RT,82803,HCPCS,300,RC,8097094,CDM,,,,OUTPATIENT,,, 398.48, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 338.71,,OUTPCT LIMIT, 203.52,OTHER, 37.54, 390.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46712,GASTRIN TC,82941,HCPCS,300,RC,9285794,CDM,,,,OUTPATIENT,,, 114.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 96.90,,OUTPCT LIMIT, 61.71,OTHER, 25.39, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46713,GLUCOSE CSF TC,82945,HCPCS,300,RC,9327260,CDM,,,,OUTPATIENT,,, 49.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 42.29,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46714,GLUCOSE FLUID TC,82945,HCPCS,300,RC,9284842,CDM,,,,OUTPATIENT,,, 49.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 42.29,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46715,GLUCOSE SYNOVIAL FL TC,82945,HCPCS,300,RC,9332243,CDM,,,,OUTPATIENT,,, 49.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 42.29,,OUTPCT LIMIT, 25.64,OTHER, 5.66, 48.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46716,GLUCOSE 1 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045331,CDM,,,,OUTPATIENT,,, 55.23, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 46.95,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46717,GLUCOSE LVL,82947,HCPCS,300,RC,633594,CDM,,,,OUTPATIENT,,, 55.23, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 46.95,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46718,GLUCOSE 2 HOUR POST PRANDIAL,82947,HCPCS,300,RC,8045334,CDM,,,,OUTPATIENT,,, 55.23, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 46.95,,OUTPCT LIMIT, 28.32,OTHER, 5.66, 54.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46719,BLOOD GLUCOSE MONITORING CLINIC POC (RE),82947,HCPCS,521,RC,8198018,CDM,,,,OUTPATIENT,,, 26.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 22.27,,OUTPCT LIMIT, 14.14,OTHER, 5.66, 25.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46720,GLUCOSE FASTING,82950,HCPCS,300,RC,3454411,CDM,,,,OUTPATIENT,,, 128.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 109.37,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46721,GLUCOSE 4 HOUR,82950,HCPCS,300,RC,8045337,CDM,,,,OUTPATIENT,,, 128.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 109.37,,OUTPCT LIMIT, 64.46,OTHER, 6.84, 126.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46722,G-6-PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) QUANTITATIVE TC,82955,HCPCS,300,RC,9285782,CDM,,,,OUTPATIENT,,, 111.79, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 95.02,,OUTPCT LIMIT, 57.91,OTHER, 13.97, 109.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46723,GGT (GAMMA GLUTAMYL TRANSPEPTIDASE) TC,82977,HCPCS,300,RC,9282576,CDM,,,,OUTPATIENT,,, 71.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 61.06,,OUTPCT LIMIT, 37.55,OTHER, 10.37, 70.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46724,FOLLICLE STIMULATING HORMONE LEVEL,83001,HCPCS,300,RC,3170314,CDM,,,,OUTPATIENT,,, 180.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 153.81,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46725,FSH (FOLLICLE STIMULATING HORMONE) TC,83001,HCPCS,300,RC,9282535,CDM,,,,OUTPATIENT,,, 180.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 153.81,,OUTPCT LIMIT, 94.73,OTHER, 26.76, 177.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46726,LUTEINIZING HORMONE,83002,HCPCS,300,RC,4240834,CDM,,,,OUTPATIENT,,, 180.56, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 153.48,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46727,LH-LUTEINIZING HORMONE TC,83002,HCPCS,300,RC,9296819,CDM,,,,OUTPATIENT,,, 180.56, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 153.48,,OUTPCT LIMIT, 94.52,OTHER, 26.66, 176.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46728,HAPTOGLOBIN TC,83010,HCPCS,300,RC,9285810,CDM,,,,OUTPATIENT,,, 128.47, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 109.20,,OUTPCT LIMIT, 67.05,OTHER, 18.12, 125.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46729,COBALT WHOLE BLOOD TC,83018,HCPCS,300,RC,9337203,CDM,,,,OUTPATIENT,,, 138.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 117.30,,OUTPCT LIMIT, 74.92,OTHER, 31.62, 135.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46730,HEMOGLOBIN A1C,83036,HCPCS,300,RC,8135646,CDM,,,,OUTPATIENT,,, 92.10, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 78.29,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46731,HEMOGLOBIN A1C (GLYCATED HEMOGLOBIN) TC,83036,HCPCS,300,RC,9285859,CDM,,,,OUTPATIENT,,, 92.10, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 78.29,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46732,HEMOGLOBIN A1C,83036,HCPCS,300,RC,1383763,CDM,,,,OUTPATIENT,,, 92.10, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 78.29,,OUTPCT LIMIT, 48.30,OTHER, 13.98, 90.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46733,HOMOCYSTEINE TC,83090,HCPCS,300,RC,9282681,CDM,,,,OUTPATIENT,,, 191.86, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 163.08,,OUTPCT LIMIT, 99.83,OTHER, 25.80, 188.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46734,GLIADIN IGG AB TC,83516,HCPCS,300,RC,9239017,CDM,,,,OUTPATIENT,,, 301.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 255.85,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46735,ACHR MODULATINGSER TC,83516,HCPCS,300,RC,9248318,CDM,,,,OUTPATIENT,,, 265.38, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 225.57,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46736,ACETYLCHOLINE RECEPTOR ANTIBODY REFLEXIVE PANEL TC,83516,HCPCS,300,RC,9257318,CDM,,,,OUTPATIENT,,, 265.38, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 225.57,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46737,ACETYLCHOLINE RECEPTOR BINDING ANTIBODIES TC,83516,HCPCS,300,RC,9249537,CDM,,,,OUTPATIENT,,, 265.38, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 225.57,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46738,ACETYLCHOLINE RECEPTOR MODULATING ANTIBODIES TC,83516,HCPCS,300,RC,9249529,CDM,,,,OUTPATIENT,,, 265.38, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 225.57,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46739,ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODIES TC,83516,HCPCS,300,RC,9249546,CDM,,,,OUTPATIENT,,, 265.38, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 225.57,,OUTPCT LIMIT, 136.44,OTHER, 16.61, 294.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46740,PANCREA.ELASTASEFEC TC,83520,HCPCS,300,RC,9282531,CDM,,,,OUTPATIENT,,, 296.61, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 252.12,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46741,TSH (THYROID STIMULATING HORMONE) RECEPTOR ANTIBODIES TC,83520,HCPCS,300,RC,9338257,CDM,,,,OUTPATIENT,,, 179.06, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 152.20,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46742,GBM (GLOMERULAR BASEMENT MEMBRANE) ANTIBODIES IGG TC,83520,HCPCS,300,RC,9282569,CDM,,,,OUTPATIENT,,, 276.09, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 234.68,,OUTPCT LIMIT, 128.28,OTHER, 24.86, 290.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46743,KAPPA LAMBDA/RATIO TC,83521,HCPCS,300,RC,9296779,CDM,,,,OUTPATIENT,,, 43.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 36.55,,OUTPCT LIMIT, 25.93,OTHER, 18.49, 42.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46744,INSULIN TC,83525,HCPCS,300,RC,9288619,CDM,,,,OUTPATIENT,,, 133.36, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 113.36,,OUTPCT LIMIT, 69.04,OTHER, 16.46, 130.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46745,IRON LEVEL,83540,HCPCS,300,RC,7050169,CDM,,,,OUTPATIENT,,, 85.32, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.52,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46746,IRON LC,83540,HCPCS,300,RC,9531157,CDM,,,,OUTPATIENT,,, 85.32, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.52,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46747,IRON LEVEL,83540,HCPCS,300,RC,633765,CDM,,,,OUTPATIENT,,, 85.32, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.52,,OUTPCT LIMIT, 43.88,OTHER, 9.31, 83.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46748,IRON BIND.CAP.(TIBC) LC,83550,HCPCS,300,RC,9531156,CDM,,,,OUTPATIENT,,, 104.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 88.74,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46749,IRON AND TIBC (IRON BINDING CAPACITY) TC,83550,HCPCS,300,RC,9275920,CDM,,,,OUTPATIENT,,, 104.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 88.74,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46750,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,8045341,CDM,,,,OUTPATIENT,,, 104.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 88.74,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46751,TOTAL IRON BINDING CAPACITY,83550,HCPCS,300,RC,7050172,CDM,,,,OUTPATIENT,,, 104.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 88.74,,OUTPCT LIMIT, 53.98,OTHER, 12.59, 102.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46752,LACTIC ACID LEVEL,83605,HCPCS,300,RC,8057612,CDM,,,,OUTPATIENT,,, 135.30, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 115.01,,OUTPCT LIMIT, 70.04,OTHER, 16.66, 132.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46753,LDH (LACTATE DEHYDROGENASE) FLUID TC,83615,HCPCS,300,RC,9282527,CDM,,,,OUTPATIENT,,, 86.46, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.49,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46754,LACTATE DEHYDROGENASE,83615,HCPCS,300,RC,633770,CDM,,,,OUTPATIENT,,, 113.92, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 96.83,,OUTPCT LIMIT, 51.00,OTHER, 8.70, 111.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46755,LDH (LACTATE DEHYDROGENASE) ISOENZYMES TC,83625,HCPCS,300,RC,9296809,CDM,,,,OUTPATIENT,,, 166.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 141.10,,OUTPCT LIMIT, 85.45,OTHER, 18.42, 162.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46756,LACTOFERRIN QUALITATIVE,83630,HCPCS,300,RC,8727426,CDM,,,,OUTPATIENT,,, 127.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 107.95,,OUTPCT LIMIT, 68.77,OTHER, 28.37, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46757,LEAD BLOOD TC,83655,HCPCS,300,RC,9348395,CDM,,,,OUTPATIENT,,, 103.65, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 88.10,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46758,LEAD BLOOD (VENOUS) TC,83655,HCPCS,300,RC,9294434,CDM,,,,OUTPATIENT,,, 103.65, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 88.10,,OUTPCT LIMIT, 54.77,OTHER, 17.44, 101.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46759,LIPASE LEVEL,83690,HCPCS,300,RC,633776,CDM,,,,OUTPATIENT,,, 119.01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 101.16,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46760,LIPASE TC,83690,HCPCS,300,RC,9300130,CDM,,,,OUTPATIENT,,, 119.01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 101.16,,OUTPCT LIMIT, 60.48,OTHER, 9.92, 116.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46761,PHOSPH A2 RCP AB IGG TC,83698,HCPCS,300,RC,9326296,CDM,,,,OUTPATIENT,,, 272.72, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 231.81,,OUTPCT LIMIT, 149.05,OTHER, 66.68, 267.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46762,LIPOFIT BY NMR TC,83704,HCPCS,300,RC,9300132,CDM,,,,OUTPATIENT,,, 65.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 55.25,,OUTPCT LIMIT, 43.46,OTHER, 27.95, 63.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46763,DIRECT LDL TC,83721,HCPCS,300,RC,9275066,CDM,,,,OUTPATIENT,,, 80.70, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 68.60,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46764,LDL DIRECT,83721,HCPCS,300,RC,3170346,CDM,,,,OUTPATIENT,,, 80.70, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 68.60,,OUTPCT LIMIT, 43.01,OTHER, 15.12, 79.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46765,MAGNESIUM LEVEL,83735,HCPCS,300,RC,633781,CDM,,,,OUTPATIENT,,, 78.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 66.74,,OUTPCT LIMIT, 40.64,OTHER, 9.65, 76.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46766,BILE ACIDS FRACTIONATED AND TOTAL TC,83789,HCPCS,300,RC,9255019,CDM,,,,OUTPATIENT,,, 400.91, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 340.77,,OUTPCT LIMIT, 204.04,OTHER, 34.72, 392.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46767,WHOLE BLOOD MERCURY TC,83825,HCPCS,300,RC,9348396,CDM,,,,OUTPATIENT,,, 106.32, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 90.37,,OUTPCT LIMIT, 57.49,OTHER, 23.41, 104.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46768,METANEPHRINES PLASMA FREE TC,83835,HCPCS,300,RC,9326301,CDM,,,,OUTPATIENT,,, 314.87, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 267.64,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46769,METANEPHRINES FRACTIONATED BY HPLC-MS/MS URINE TC,83835,HCPCS,300,RC,9338323,CDM,,,,OUTPATIENT,,, 314.87, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 267.64,,OUTPCT LIMIT, 159.56,OTHER, 24.40, 308.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46770,MYOGLOBIN URINE TC,83874,HCPCS,300,RC,9338710,CDM,,,,OUTPATIENT,,, 166.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 141.67,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46771,MYOGLOBIN SERUM TC,83874,HCPCS,300,RC,9313589,CDM,,,,OUTPATIENT,,, 121.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 103.29,,OUTPCT LIMIT, 74.79,OTHER, 18.60, 163.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46772,BNP,83880,HCPCS,300,RC,1383771,CDM,,,,OUTPATIENT,,, 219.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 186.15,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46773,N-TERMINAL PRO BNP,83880,HCPCS,300,RC,1503769,CDM,,,,OUTPATIENT,,, 219.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 186.15,,OUTPCT LIMIT, 120.40,OTHER, 56.53, 214.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46774,METHYLMALONIC ACID SERUM QUANTITATIVE TC,83921,HCPCS,300,RC,9310645,CDM,,,,OUTPATIENT,,, 212.33, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 180.48,,OUTPCT LIMIT, 110.95,OTHER, 30.54, 208.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46775,OSMOLALITY,83930,HCPCS,300,RC,4186066,CDM,,,,OUTPATIENT,,, 106.29, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 90.35,,OUTPCT LIMIT, 54.17,OTHER, 9.52, 104.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46776,OSMOLALITY URINE,83935,HCPCS,300,RC,4186098,CDM,,,,OUTPATIENT,,, 86.24, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.30,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46777,OSMOLALITY URINE TC,83935,HCPCS,300,RC,9337137,CDM,,,,OUTPATIENT,,, 86.24, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.30,,OUTPCT LIMIT, 44.45,OTHER, 9.82, 84.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46778,OXALATE URINE 24 HOUR TC,83945,HCPCS,300,RC,9336861,CDM,,,,OUTPATIENT,,, 166.27, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 141.33,,OUTPCT LIMIT, 86.15,OTHER, 20.81, 162.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46779,PTH INTACT TC,83970,HCPCS,300,RC,9326380,CDM,,,,OUTPATIENT,,, 272.05, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 231.24,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46780,PTH INTACT,83970,HCPCS,300,RC,3455483,CDM,,,,OUTPATIENT,,, 272.05, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 231.24,,OUTPCT LIMIT, 147.00,OTHER, 59.45, 266.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46781,PCP URINE QN TC,83992,HCPCS,300,RC,9247110,CDM,,,,OUTPATIENT,,, 76.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 64.60,,OUTPCT LIMIT, 43.75,OTHER, 27.89, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46782,FECAL CALPROTECTIN BY ELISA IGG TC,83993,HCPCS,300,RC,9275911,CDM,,,,OUTPATIENT,,, 368.37, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 313.11,,OUTPCT LIMIT, 186.61,OTHER, 28.27, 361.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46783,ALKALINE PHOSPHATASE ISOENZYMES TC,84075,HCPCS,300,RC,9250790,CDM,,,,OUTPATIENT,,, 86.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.10,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46784,ALKALINE PHOSPHATASE,84075,HCPCS,300,RC,1620878,CDM,,,,OUTPATIENT,,, 94.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 80.41,,OUTPCT LIMIT, 45.87,OTHER, 7.46, 92.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46785,PHOSPHORUS LEVEL,84100,HCPCS,300,RC,633803,CDM,,,,OUTPATIENT,,, 68.74, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 58.43,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46786,PHOSPHORUS TC,84100,HCPCS,300,RC,9326311,CDM,,,,OUTPATIENT,,, 68.74, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 58.43,,OUTPCT LIMIT, 35.19,OTHER, 6.83, 67.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46787,POTASSIUM LVL,84132,HCPCS,300,RC,633616,CDM,,,,OUTPATIENT,,, 55.78, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 47.41,,OUTPCT LIMIT, 28.87,OTHER, 6.85, 54.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46788,POTASSIUM URINE RANDOM TC,84133,HCPCS,300,RC,9338706,CDM,,,,OUTPATIENT,,, 25.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 21.25,,OUTPCT LIMIT, 13.83,OTHER, 6.82, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46789,PREALBUMIN TC,84134,HCPCS,300,RC,9321244,CDM,,,,OUTPATIENT,,, 83.06, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 70.60,,OUTPCT LIMIT, 45.56,OTHER, 21.01, 81.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46790,PROGESTERONE LEVEL,84144,HCPCS,300,RC,3454459,CDM,,,,OUTPATIENT,,, 175.24, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 148.95,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46791,PROGESTERONE TC,84144,HCPCS,300,RC,9321403,CDM,,,,OUTPATIENT,,, 175.24, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 148.95,,OUTPCT LIMIT, 92.72,OTHER, 30.04, 171.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46792,PROCALCITONIN TC,84145,HCPCS,300,RC,9326285,CDM,,,,OUTPATIENT,,, 191.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 162.69,,OUTPCT LIMIT, 102.79,OTHER, 39.19, 187.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46793,PROLACTIN LEVEL,84146,HCPCS,300,RC,3170316,CDM,,,,OUTPATIENT,,, 185.38, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 157.57,,OUTPCT LIMIT, 97.17,OTHER, 27.91, 181.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46794,PSA-TOTAL,84153,HCPCS,300,RC,8169860,CDM,,,,OUTPATIENT,,, 165.31, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 140.51,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46795,PSA (PROSTATE SPECIFIC ANTIGEN) PERCENT FREE INCLUDES TOTAL TC,84153,HCPCS,300,RC,9326375,CDM,,,,OUTPATIENT,,, 178.34, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 151.59,,OUTPCT LIMIT, 90.21,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46796,PSA (PROSTATE SPECIFIC ANTIGEN) TC,84154,HCPCS,300,RC,9326374,CDM,,,,OUTPATIENT,,, 178.34, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 151.59,,OUTPCT LIMIT, 93.39,OTHER, 26.48, 174.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46797,PROTEIN TOTAL SERUM OR PLASMA TC,84155,HCPCS,300,RC,9333754,CDM,,,,OUTPATIENT,,, 47.92, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 40.73,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46798,PROTEIN TOTAL,84155,HCPCS,300,RC,633818,CDM,,,,OUTPATIENT,,, 47.92, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 40.73,,OUTPCT LIMIT, 24.66,OTHER, 5.28, 46.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46799,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9353891,CDM,,,,OUTPATIENT,,, 115.87, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 98.49,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46800,PROTEIN TOTAL URINE 24 HOUR TC,84156,HCPCS,300,RC,9338571,CDM,,,,OUTPATIENT,,, 115.87, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 98.49,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46801,UR TOTAL PROTEIN TC,84156,HCPCS,300,RC,9338776,CDM,,,,OUTPATIENT,,, 115.87, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 98.49,,OUTPCT LIMIT, 57.84,OTHER, 5.28, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46802,TOTAL PROTEIN SYNFL TC,84157,HCPCS,300,RC,9332245,CDM,,,,OUTPATIENT,,, 81.80, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 69.53,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46803,PROTEIN TOTAL BODY FLUID TC,84157,HCPCS,300,RC,9284843,CDM,,,,OUTPATIENT,,, 81.80, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 69.53,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46804,PROTEIN TOTAL CSF TC,84157,HCPCS,300,RC,9332208,CDM,,,,OUTPATIENT,,, 85.42, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.61,,OUTPCT LIMIT, 41.90,OTHER, 5.76, 83.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46805,MONOCLONAL PROTEIN MONITORING SERUM TC,84165,HCPCS,300,RC,9332218,CDM,,,,OUTPATIENT,,, 398.09, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 338.38,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46806,ALBUMIN/GLOBULIN RATIO,84165,HCPCS,300,RC,8045374,CDM,,,,OUTPATIENT,,, 176.86, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 150.33,,OUTPCT LIMIT, 144.06,OTHER, 15.47, 390.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46807,PROTEIN ELECTROPHORESIS W ISOTYPEUR 24HR TC,84166,HCPCS,300,RC,9338744,CDM,,,,OUTPATIENT,,, 152.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 129.64,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46808,PROTEIN ELECTROPHORESIS REFLEX ISOTYPEUR RAN TC,84166,HCPCS,300,RC,9337155,CDM,,,,OUTPATIENT,,, 402.37, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 342.01,,OUTPCT LIMIT, 141.59,OTHER, 25.68, 394.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46809,PROINSULIN TC,84206,HCPCS,300,RC,9321405,CDM,,,,OUTPATIENT,,, 260.48, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 221.41,,OUTPCT LIMIT, 136.35,OTHER, 38.44, 255.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46810,VITAMIN B6 (PYRIDOXINE) TOTAL TC,84207,HCPCS,300,RC,9337194,CDM,,,,OUTPATIENT,,, 191.76, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 163.00,,OUTPCT LIMIT, 103.27,OTHER, 40.46, 187.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46811,RENIN ACTIVITY TC,84244,HCPCS,300,RC,9326396,CDM,,,,OUTPATIENT,,, 142.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 120.70,,OUTPCT LIMIT, 76.88,OTHER, 31.67, 139.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46812,VITAMIN B2 (RIBOFLAVIN) TC,84252,HCPCS,300,RC,9338784,CDM,,,,OUTPATIENT,,, 352.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 299.20,,OUTPCT LIMIT, 178.83,OTHER, 29.15, 344.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46813,SEX HORMONE BINDING GLOBULIN TC,84270,HCPCS,300,RC,9332210,CDM,,,,OUTPATIENT,,, 165.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 140.96,,OUTPCT LIMIT, 88.43,OTHER, 31.30, 162.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46814,SODIUM,84295,HCPCS,300,RC,633611,CDM,,,,OUTPATIENT,,, 58.10, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 49.39,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46815,SODIUM TC,84295,HCPCS,300,RC,9319366,CDM,,,,OUTPATIENT,,, 58.10, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 49.39,,OUTPCT LIMIT, 30.02,OTHER, 6.92, 56.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46816,SODIUM URINE RANDOM TC,84300,HCPCS,300,RC,9337133,CDM,,,,OUTPATIENT,,, 90.37, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 76.81,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46817,SODIUM LEVEL URINE,84300,HCPCS,300,RC,4185817,CDM,,,,OUTPATIENT,,, 90.37, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 76.81,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46818,SODIUM URINE 24 HOUR TC,84300,HCPCS,300,RC,9338324,CDM,,,,OUTPATIENT,,, 18.55, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 15.77,,OUTPCT LIMIT, 34.17,OTHER, 7.28, 88.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46819,INSULIN-LIKE GROWTH FACTOR 1 (IGF1) SOMATOMEDIN C TC,84305,HCPCS,300,RC,9288581,CDM,,,,OUTPATIENT,,, 355.17, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 301.89,,OUTPCT LIMIT, 180.72,OTHER, 30.61, 348.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46820,PORPHYRINS PLASMA TC,84311,HCPCS,300,RC,9321429,CDM,,,,OUTPATIENT,,, 614.72, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 522.51,,OUTPCT LIMIT, 302.95,OTHER, 11.66, 602.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46821,TESTOSTERONE FREE AND TOTAL ADULT MALES ONLY TC,84402,HCPCS,300,RC,9332262,CDM,,,,OUTPATIENT,,, 149.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 127.36,,OUTPCT LIMIT, 81.90,OTHER, 36.67, 146.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46822,TOTAL TESTO F/PEDS TC,84403,HCPCS,300,RC,9339053,CDM,,,,OUTPATIENT,,, 234.02, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 198.92,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46823,FREE TESTO F/PEDS TC,84403,HCPCS,300,RC,9338260,CDM,,,,OUTPATIENT,,, 234.02, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 198.92,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46824,TESTOSTERONE LEVEL TOTAL,84403,HCPCS,300,RC,3170320,CDM,,,,OUTPATIENT,,, 234.02, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 198.92,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46825,TESTOSTERONE TOTAL ADULT MALES ONLY TC,84403,HCPCS,300,RC,9333747,CDM,,,,OUTPATIENT,,, 234.02, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 198.92,,OUTPCT LIMIT, 123.12,OTHER, 37.16, 229.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46826,VITAMIN B1 (THIAMINE) PLASMA TC,84425,HCPCS,300,RC,9326385,CDM,,,,OUTPATIENT,,, 162.84, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 138.41,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46827,VITAMIN B1 (THIAMINE) WHOLE BLOOD TC,84425,HCPCS,300,RC,9338788,CDM,,,,OUTPATIENT,,, 162.84, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 138.41,,OUTPCT LIMIT, 86.80,OTHER, 30.58, 159.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46828,THYROGLOBULIN LCMS TC,84432,HCPCS,300,RC,9335052,CDM,,,,OUTPATIENT,,, 208.57, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 177.28,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46829,THYROGLOBULIN ANTIBODY TC,84432,HCPCS,300,RC,9255017,CDM,,,,OUTPATIENT,,, 208.57, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 177.28,,OUTPCT LIMIT, 107.35,OTHER, 23.12, 204.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46830,T4-THYROXINE TC,84436,HCPCS,300,RC,9332253,CDM,,,,OUTPATIENT,,, 104.27, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 88.63,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46831,T4 TOTAL,84436,HCPCS,300,RC,633845,CDM,,,,OUTPATIENT,,, 104.27, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 88.63,,OUTPCT LIMIT, 53.27,OTHER, 9.89, 102.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46832,T4 (THYROXINE) FREE TC,84439,HCPCS,300,RC,9282537,CDM,,,,OUTPATIENT,,, 149.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 126.82,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46833,FREE T4 (FREE THYROXINE) AEL,84439,HCPCS,300,RC,8078800,CDM,,,,OUTPATIENT,,, 149.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 126.82,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46834,FREE T4 LEVEL,84439,HCPCS,300,RC,3170324,CDM,,,,OUTPATIENT,,, 149.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 126.82,,OUTPCT LIMIT, 75.95,OTHER, 12.98, 146.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46835,THYROXINE BINDING GLOBULIN TC,84442,HCPCS,300,RC,9332258,CDM,,,,OUTPATIENT,,, 96.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 81.60,,OUTPCT LIMIT, 51.95,OTHER, 21.29, 94.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46836,TSH,84443,HCPCS,300,RC,633844,CDM,,,,OUTPATIENT,,, 138.79, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 117.97,,OUTPCT LIMIT, 73.53,OTHER, 24.19, 136.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46837,TSH -THYROID STIMULATING HORMONE (3RD GENERATION/ULTRASENSITIVE) TC,84445,HCPCS,300,RC,9338246,CDM,,,,OUTPATIENT,,, 280.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 238.00,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46838,THYROID STIM IMMG TC,84445,HCPCS,300,RC,9338258,CDM,,,,OUTPATIENT,,, 280.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 238.00,,OUTPCT LIMIT, 154.17,OTHER, 73.24, 274.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46839,VITAMIN E SERUM OR PLASMA TC,84446,HCPCS,300,RC,9337195,CDM,,,,OUTPATIENT,,, 92.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 78.20,,OUTPCT LIMIT, 49.79,OTHER, 20.42, 90.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46840,ASPARTATE AMINOTRANSFERASE,84450,HCPCS,300,RC,633633,CDM,,,,OUTPATIENT,,, 74.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 63.61,,OUTPCT LIMIT, 38.32,OTHER, 7.46, 73.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46841,ALANINE AMINOTRANSFERASE,84460,HCPCS,300,RC,633632,CDM,,,,OUTPATIENT,,, 69.98, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 59.48,,OUTPCT LIMIT, 35.99,OTHER, 7.63, 68.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46842,TRANSFERRIN TC,84466,HCPCS,300,RC,9333757,CDM,,,,OUTPATIENT,,, 110.86, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 94.23,,OUTPCT LIMIT, 58.51,OTHER, 18.37, 108.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46843,TRIGLYCERIDES,84478,HCPCS,300,RC,633852,CDM,,,,OUTPATIENT,,, 76.11, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 64.69,,OUTPCT LIMIT, 39.13,OTHER, 8.27, 74.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46844,T3 TOTAL,84480,HCPCS,300,RC,633833,CDM,,,,OUTPATIENT,,, 152.66, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 129.76,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46845,T3 -TRIIODOTHYRONINE TOTAL TC,84480,HCPCS,300,RC,9332246,CDM,,,,OUTPATIENT,,, 152.66, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 129.76,,OUTPCT LIMIT, 79.41,OTHER, 20.42, 149.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46846,T3 (TRIIODOTHYRONINE) FREE TC,84481,HCPCS,300,RC,9282536,CDM,,,,OUTPATIENT,,, 149.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 127.23,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46847,T3 FREE,84481,HCPCS,300,RC,3170323,CDM,,,,OUTPATIENT,,, 149.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 127.23,,OUTPCT LIMIT, 78.90,OTHER, 24.40, 146.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46848,REVERSE T3 (TRIIODOTHYRONINE REVERSE) TC,84482,HCPCS,300,RC,9329251,CDM,,,,OUTPATIENT,,, 248.78, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 211.46,,OUTPCT LIMIT, 126.89,OTHER, 22.69, 243.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46849,TROPONIN-I,84484,HCPCS,300,RC,8231581,CDM,,,,OUTPATIENT,,, 161.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 137.02,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46850,TROP-I,84484,HCPCS,300,RC,1634892,CDM,,,,OUTPATIENT,,, 161.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 137.02,,OUTPCT LIMIT, 82.99,OTHER, 17.95, 157.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46851,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,633605,CDM,,,,OUTPATIENT,,, 77.35, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 65.75,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46852,BLOOD UREA NITROGEN,84520,HCPCS,300,RC,8045640,CDM,,,,OUTPATIENT,,, 77.35, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 65.75,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46853,BUN (BLOOD UREA NITROGEN) TC,84520,HCPCS,300,RC,9258417,CDM,,,,OUTPATIENT,,, 77.35, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 65.75,,OUTPCT LIMIT, 39.13,OTHER, 5.69, 75.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46854,UREA NITROGEN URINE RANDOM TC,84540,HCPCS,300,RC,9338778,CDM,,,,OUTPATIENT,,, 42.38, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 36.02,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46855,UREA NITROGEN URINE 24 HOUR TC,84540,HCPCS,300,RC,9336913,CDM,,,,OUTPATIENT,,, 42.38, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 36.02,,OUTPCT LIMIT, 22.60,OTHER, 8.00, 41.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46856,URIC ACID,84550,HCPCS,300,RC,633858,CDM,,,,OUTPATIENT,,, 62.10, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 52.79,,OUTPCT LIMIT, 31.87,OTHER, 6.50, 60.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46857,URIC ACID URINE RANDOM TC,84560,HCPCS,300,RC,9337159,CDM,,,,OUTPATIENT,,, 76.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 65.03,,OUTPCT LIMIT, 39.10,OTHER, 7.32, 74.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46858,VITAMIN A (RETINOL) SERUM OR PLASMA TC,84590,HCPCS,300,RC,9337187,CDM,,,,OUTPATIENT,,, 148.17, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 125.94,,OUTPCT LIMIT, 76.33,OTHER, 16.72, 145.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46859,VITAMIN K1 TC,84597,HCPCS,300,RC,9338786,CDM,,,,OUTPATIENT,,, 202.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 172.34,,OUTPCT LIMIT, 103.71,OTHER, 19.75, 198.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46860,ZINC SERUM/PLASMA TC,84630,HCPCS,300,RC,9337205,CDM,,,,OUTPATIENT,,, 108.08, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 91.87,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46861,ZINC TRANS. 8 AB TC,84630,HCPCS,300,RC,9338789,CDM,,,,OUTPATIENT,,, 108.08, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 91.87,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46862,ZINC QUANTITATIVE WHOLE BLOOD TC,84630,HCPCS,300,RC,9338790,CDM,,,,OUTPATIENT,,, 108.08, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 91.87,,OUTPCT LIMIT, 56.68,OTHER, 16.40, 105.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46863,C-PEPTIDE SERUM TC,84681,HCPCS,300,RC,9272504,CDM,,,,OUTPATIENT,,, 160.70, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 136.60,,OUTPCT LIMIT, 85.61,OTHER, 29.96, 157.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46864,BETA HCG QUANTITATIVE,84702,HCPCS,300,RC,633665,CDM,,,,OUTPATIENT,,, 188.15, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 159.93,,OUTPCT LIMIT, 97.04,OTHER, 21.67, 184.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46865,BLEEDING TIME,85002,HCPCS,300,RC,633674,CDM,,,,OUTPATIENT,,, 84.43, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 71.77,,OUTPCT LIMIT, 42.88,OTHER, 6.94, 82.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46866,MANUAL DIFFERENTIAL VIST,85007,HCPCS,300,RC,9357207,CDM,,,,OUTPATIENT,,, 87.03, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.98,,OUTPCT LIMIT, 43.80,OTHER, 5.47, 85.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46867,HEMATOCRIT,85014,HCPCS,300,RC,1635636,CDM,,,,OUTPATIENT,,, 34.89, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 29.66,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46868,HCT,85014,HCPCS,300,RC,633742,CDM,,,,OUTPATIENT,,, 34.89, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 29.66,,OUTPCT LIMIT, 17.85,OTHER, 3.41, 34.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46869,HGB,85018,HCPCS,300,RC,633741,CDM,,,,OUTPATIENT,,, 42.28, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 35.94,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46870,HEMOGLOBIN,85018,HCPCS,300,RC,1635635,CDM,,,,OUTPATIENT,,, 42.28, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 35.94,,OUTPCT LIMIT, 21.46,OTHER, 3.41, 41.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46871,CBC (COMPLETE BLOOD COUNT) PATHOLOGIST SLIDE REVIEW TC,85025,HCPCS,300,RC,9313612,CDM,,,,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46872,AUTO DIFF,85025,HCPCS,300,RC,633875,CDM,,,,OUTPATIENT,,, 85.91, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.02,,OUTPCT LIMIT, 22.31,OTHER, .01, 84.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46873,CBC W/O DIFF,85027,HCPCS,300,RC,3798345,CDM,,,,OUTPATIENT,,, 87.02, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.97,,OUTPCT LIMIT, 44.71,OTHER, 9.31, 85.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46874,RETICULOCYTE COUNT AUTOMATED TC,85045,HCPCS,300,RC,9321441,CDM,,,,OUTPATIENT,,, 74.31, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 63.16,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46875,RETIC CNT AUTO,85045,HCPCS,300,RC,3455503,CDM,,,,OUTPATIENT,,, 74.31, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 63.16,,OUTPCT LIMIT, 37.65,OTHER, 5.75, 72.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46876,WBC,85048,HCPCS,300,RC,633873,CDM,,,,OUTPATIENT,,, 39.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 33.15,,OUTPCT LIMIT, 19.92,OTHER, 3.66, 38.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46877,PLT CNT,85049,HCPCS,300,RC,2182297,CDM,,,,OUTPATIENT,,, 63.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 54.12,,OUTPCT LIMIT, 32.63,OTHER, 6.46, 62.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46878,FACTOR VIII ACTIVITY TC,85240,HCPCS,300,RC,9275910,CDM,,,,OUTPATIENT,,, 185.61, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 157.77,,OUTPCT LIMIT, 96.77,OTHER, 25.78, 181.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46879,VON WILLEBRAND FACTOR ANTIGEN TC,85246,HCPCS,300,RC,9337198,CDM,,,,OUTPATIENT,,, 248.69, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 211.39,,OUTPCT LIMIT, 129.31,OTHER, 33.04, 243.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46880,ANTITHROMBIN III ACTIVITY TC,85300,HCPCS,300,RC,9251838,CDM,,,,OUTPATIENT,,, 259.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 220.15,,OUTPCT LIMIT, 130.54,OTHER, 17.06, 253.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46881,PROTEIN C ACTIVITY TC,85303,HCPCS,300,RC,9321407,CDM,,,,OUTPATIENT,,, 191.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 162.92,,OUTPCT LIMIT, 98.34,OTHER, 19.93, 187.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46882,PROTEIN S FREE ANTIGEN TC,85306,HCPCS,300,RC,9326376,CDM,,,,OUTPATIENT,,, 171.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 145.78,,OUTPCT LIMIT, 89.00,OTHER, 22.06, 168.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46883,DDIMER,85379,HCPCS,300,RC,3454398,CDM,,,,OUTPATIENT,,, 194.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 164.90,,OUTPCT LIMIT, 98.22,OTHER, 14.66, 190.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46884,FIBRINOGEN ACTIVITY TC,85384,HCPCS,300,RC,9280333,CDM,,,,OUTPATIENT,,, 105.06, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.30,,OUTPCT LIMIT, 54.63,OTHER, 13.99, 102.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46885,LYSOZYME SERUM TC,85549,HCPCS,300,RC,9294764,CDM,,,,OUTPATIENT,,, 131.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 111.35,,OUTPCT LIMIT, 70.40,OTHER, 27.00, 128.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46886,INR,85610,HCPCS,300,RC,8621135,CDM,,,,OUTPATIENT,,, 58.26, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 49.52,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46887,PT (PROTHROMBIN TIME) FROZEN TC,85610,HCPCS,300,RC,9282532,CDM,,,,OUTPATIENT,,, 57.88, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 49.20,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46888,PT,85610,HCPCS,300,RC,633793,CDM,,,,OUTPATIENT,,, 58.26, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 49.52,,OUTPCT LIMIT, 29.86,OTHER, 6.18, 57.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46889,PT/INR CLINIC POC (RE),85610,HCPCS,521,RC,8198034,CDM,,,,OUTPATIENT,,, 26.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 22.10,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46890,INR CLINIC POC (RE),85610,HCPCS,521,RC,9583249,CDM,,,,OUTPATIENT,,, 26.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 22.10,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46891,INR POC RE,85610,HCPCS,521,RC,9009183,CDM,,,,OUTPATIENT,,, 26.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 22.10,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46892,INR POC (RE),85610,HCPCS,521,RC,9087166,CDM,,,,OUTPATIENT,,, 26.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 22.10,,OUTPCT LIMIT, 14.17,OTHER, 6.18, 25.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46893,ESR (ERYTHROCYTE SEDIMENTATION RATE) WESTERGREN TC,85651,HCPCS,300,RC,9279276,CDM,,,,OUTPATIENT,,, 82.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 69.87,,OUTPCT LIMIT, 41.60,OTHER, 6.14, 80.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46894,ESR WESTERGREN,85652,HCPCS,300,RC,1902793,CDM,,,,OUTPATIENT,,, 52.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 44.20,,OUTPCT LIMIT, 26.32,OTHER, 3.89, 50.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46895,SICKLE CELL SCREEN SF,85660,HCPCS,300,RC,9332212,CDM,,,,OUTPATIENT,,, 70.57, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 59.98,,OUTPCT LIMIT, 36.35,OTHER, 7.93, 69.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46896,PTT,85730,HCPCS,300,RC,633794,CDM,,,,OUTPATIENT,,, 170.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 144.50,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46897,PTT (PARTIAL THROMBOPLASTIN TIME) FROZEN TC,85730,HCPCS,300,RC,9282533,CDM,,,,OUTPATIENT,,, 74.88, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 63.65,,OUTPCT LIMIT, 61.85,OTHER, 8.65, 166.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46898,ALLERGEN FOOD CASEIN (COW'S MILK) IGG TC,86001,HCPCS,300,RC,9291528,CDM,,,,OUTPATIENT,,, 151.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 128.79,,OUTPCT LIMIT, 76.67,OTHER, 11.26, 148.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46899,ALLGPNLEARLY CHILD TC,86003,HCPCS,300,RC,9291596,CDM,,,,OUTPATIENT,,, 1188.35, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1010.10,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46900,ALLG WEED C RAGWD TC,86003,HCPCS,300,RC,9291586,CDM,,,,OUTPATIENT,,, 323.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 274.55,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46901,ALLG FOOD OYSTER TC,86003,HCPCS,300,RC,9288626,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46902,ALLG FOOD PEANUT TC,86003,HCPCS,300,RC,9292201,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46903,ALLG FOOD SALMON TC,86003,HCPCS,300,RC,9296753,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46904,ALLG FOOD SCALLOP TC,86003,HCPCS,300,RC,9296754,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46905,ALLG FOOD SHRIMP TC,86003,HCPCS,300,RC,9296760,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46906,ALLG FOOD SOYBEAN TC,86003,HCPCS,300,RC,9296762,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46907,ALLG FOOD TUNA TC,86003,HCPCS,300,RC,9296764,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46908,ALLG FOOD WALNUT TC,86003,HCPCS,300,RC,9294406,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46909,ALLG FOOD WHEAT TC,86003,HCPCS,300,RC,9296767,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46910,ALLG FOODSESAME SD TC,86003,HCPCS,300,RC,9294400,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46911,ALLG GRSS BERMUDA TC,86003,HCPCS,300,RC,9291429,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46912,ALLG GRSS TIMOTHY TC,86003,HCPCS,300,RC,9294402,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46913,ALLG INSC COCKRCH TC,86003,HCPCS,300,RC,9291545,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46914,ALLG MITE D FARINAE TC,86003,HCPCS,300,RC,9288408,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46915,ALLG MOLD P NOTAT TC,86003,HCPCS,300,RC,9288636,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46916,ALLG MOLDC HERBARM TC,86003,HCPCS,300,RC,9291533,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46917,ALLG PNL ADLT FOOD TC,86003,HCPCS,300,RC,9282876,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46918,ALLG TREE ALDER TC,86003,HCPCS,300,RC,9291375,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46919,ALLG TREE ASH TC,86003,HCPCS,300,RC,9288380,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46920,ALLG TREE BIRCH TC,86003,HCPCS,300,RC,9291433,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46921,ALLG TREE CTTNWOOD TC,86003,HCPCS,300,RC,9291587,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46922,ALLG TREE ELM TC,86003,HCPCS,300,RC,9291593,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46923,ALLG TREE JUNIPER TC,86003,HCPCS,300,RC,9288587,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46924,ALLG TREE MAPLE TC,86003,HCPCS,300,RC,9292047,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46925,ALLG TREE MULBERRY TC,86003,HCPCS,300,RC,9292053,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46926,ALLG TREE OAK TC,86003,HCPCS,300,RC,9288620,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46927,ALLG TREE PECAN TC,86003,HCPCS,300,RC,9292202,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46928,ALLG TREE SYCAMORE TC,86003,HCPCS,300,RC,9296763,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46929,ALLG TREE WILLOW TC,86003,HCPCS,300,RC,9294408,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46930,ALLG WEED NETTLE TC,86003,HCPCS,300,RC,9288617,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46931,ALLG WEEDMRSH ELDR TC,86003,HCPCS,300,RC,9296751,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46932,ALLG WEEDSHP SOREL TC,86003,HCPCS,300,RC,9296755,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46933,ALLGMITED PTRNYSNS TC,86003,HCPCS,300,RC,9288410,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46934,ALLGMOLDA ALTERNRA TC,86003,HCPCS,300,RC,9291384,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46935,ALLGPNLADLT FOOD R TC,86003,HCPCS,300,RC,9286250,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46936,ALLGPNLERLY CHLD R TC,86003,HCPCS,300,RC,9288412,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46937,ALLG MOLDA FUMIGTS TC,86003,HCPCS,300,RC,9291427,CDM,,,,OUTPATIENT,,, 61.64, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 52.39,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46938,ACH REC(MUSCLE)MOD AB TC,86003,HCPCS,300,RC,9237223,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46939,ALLERGEN AMOXICILLIN (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9288384,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46940,ALLERGEN DRUGS PENICILLIN G (MAJOR) TC,86003,HCPCS,300,RC,9326286,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46941,ALLERGEN FOOD GLUTEN IGG TC,86003,HCPCS,300,RC,9291532,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46942,ALLERGENMOUSE EPITHELIUM (IMMUNOCAP IGE) TC,86003,HCPCS,300,RC,9291534,CDM,,,,OUTPATIENT,,, 32.10, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 27.29,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46943,ALLG WEED PIGWEED TC,86003,HCPCS,300,RC,9296752,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46944,ALLERGEN FOOD WHEY IGG TC,86003,HCPCS,300,RC,9291588,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46945,ALLERGENS HYMENOPTERA BEE VENOM PROFILE TC,86003,HCPCS,300,RC,9288383,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46946,ALLG ANML CAT TC,86003,HCPCS,300,RC,9288385,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46947,ALLG ANML DOG TC,86003,HCPCS,300,RC,9291589,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46948,ALLG FOOD ALMOND TC,86003,HCPCS,300,RC,9291380,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46949,ALLG FOOD BEEF TC,86003,HCPCS,300,RC,9291428,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46950,ALLG FOOD CASHEW TC,86003,HCPCS,300,RC,9291526,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46951,ALLG FOOD COD TC,86003,HCPCS,300,RC,9291585,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46952,ALLG FOOD CORN TC,86003,HCPCS,300,RC,9288406,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46953,ALLG FOOD EGG WHT TC,86003,HCPCS,300,RC,9288411,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46954,ALLG FOOD EGG YOLK TC,86003,HCPCS,300,RC,9291591,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46955,ALLG FOOD HAZELNUT TC,86003,HCPCS,300,RC,9288584,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46956,ALLG FOOD LOBSTER TC,86003,HCPCS,300,RC,9292046,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46957,ALLG FOOD MANGO TC,86003,HCPCS,300,RC,9288612,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46958,ALLG FOOD MILK TC,86003,HCPCS,300,RC,9292048,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46959,ALLG FOOD OVALBMN TC,86003,HCPCS,300,RC,9288624,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46960,ALLG FOOD OVOMCOID TC,86003,HCPCS,300,RC,9288625,CDM,,,,OUTPATIENT,,, 66.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 56.68,,OUTPCT LIMIT, 44.89,OTHER, 7.51, 1164.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46961,HEPARIN INDUCED PLATELET ANTIBODIES TC,86022,HCPCS,300,RC,9282672,CDM,,,,OUTPATIENT,,, 374.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 318.54,,OUTPCT LIMIT, 189.29,OTHER, 26.45, 367.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46962,ANCA (NEUTROPHIL CYTOPLASMIC) ANTIBODIES TC,86036,HCPCS,300,RC,9257320,CDM,,,,OUTPATIENT,,, 228.81, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 194.49,,OUTPCT LIMIT, 115.17,OTHER, 14.46, 224.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46963,ANA (NUCLEAR ANTIBODIES) SCREEN TC,86038,HCPCS,300,RC,9254561,CDM,,,,OUTPATIENT,,, 133.30, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 113.31,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46964,AUTOIMMUNE SCREEN WITH REFLEX IDENTIFICATION TC,86038,HCPCS,300,RC,9250749,CDM,,,,OUTPATIENT,,, 225.28, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 191.49,,OUTPCT LIMIT, 91.70,OTHER, 17.41, 220.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46965,ANCA TITER TC,86039,HCPCS,300,RC,9239018,CDM,,,,OUTPATIENT,,, 92.33, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 78.48,,OUTPCT LIMIT, 48.91,OTHER, 16.07, 90.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46966,ANTISTREPTOLYSIN O SCREEN,86060,HCPCS,300,RC,633657,CDM,,,,OUTPATIENT,,, 87.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 74.38,,OUTPCT LIMIT, 45.23,OTHER, 10.51, 85.75,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46967,C-REACTIVE PROTEIN,86140,HCPCS,300,RC,1628890,CDM,,,,OUTPATIENT,,, 31.34, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 26.64,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46968,CRP (C-REACTIVE PROTEIN) TC,86140,HCPCS,300,RC,9271901,CDM,,,,OUTPATIENT,,, 31.34, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 26.64,,OUTPCT LIMIT, 17.08,OTHER, 7.46, 30.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46969,CRP (C-REACTIVE PROTEIN) HIGH SENSITIVITY TC,86141,HCPCS,300,RC,9285885,CDM,,,,OUTPATIENT,,, 112.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 95.41,,OUTPCT LIMIT, 59.25,OTHER, 18.65, 110.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46970,B2 GLYCOPROTEIN PANEL TC,86146,HCPCS,300,RC,9255018,CDM,,,,OUTPATIENT,,, 174.59, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 148.40,,OUTPCT LIMIT, 93.98,OTHER, 36.65, 171.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46971,CARDIOLIPIN ANTIBODY PANEL TC,86147,HCPCS,300,RC,9272434,CDM,,,,OUTPATIENT,,, 263.45, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 223.93,,OUTPCT LIMIT, 137.37,OTHER, 36.65, 258.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46972,PHOSPHOLIPID ANTIBODY PANEL TC,86148,HCPCS,300,RC,9255591,CDM,,,,OUTPATIENT,,, 149.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 126.99,,OUTPCT LIMIT, 78.46,OTHER, 23.14, 146.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46973,COMPLEMENT C3 TC,86160,HCPCS,300,RC,9255637,CDM,,,,OUTPATIENT,,, 130.26, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 110.72,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46974,COMPLEMENT C4 TC,86160,HCPCS,300,RC,9258425,CDM,,,,OUTPATIENT,,, 129.93, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 110.44,,OUTPCT LIMIT, 67.64,OTHER, 17.28, 127.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46975,COMPLEMENT CH50 TC,86162,HCPCS,300,RC,9261179,CDM,,,,OUTPATIENT,,, 144.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 123.11,,OUTPCT LIMIT, 77.69,OTHER, 29.26, 141.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46976,CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IGG TC,86200,HCPCS,300,RC,9258722,CDM,,,,OUTPATIENT,,, 120.30, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 102.26,,OUTPCT LIMIT, 63.19,OTHER, 18.65, 117.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46977,DNA DOUBLE STRANDED ANTIBODIES TC,86225,HCPCS,300,RC,9275067,CDM,,,,OUTPATIENT,,, 120.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 102.11,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46978,ANTI DNA TITER TC,86225,HCPCS,300,RC,9250791,CDM,,,,OUTPATIENT,,, 130.41, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 110.85,,OUTPCT LIMIT, 65.88,OTHER, 19.79, 127.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46979,SM (SMITH) ANTIBODIES TC,86235,HCPCS,300,RC,9332216,CDM,,,,OUTPATIENT,,, 141.45, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 120.23,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46980,JO-1 ANTIBODIES TC,86235,HCPCS,300,RC,9296774,CDM,,,,OUTPATIENT,,, 141.45, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 120.23,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46981,SCL-70 (SCLERODERMA) ANTIBODIES TC,86235,HCPCS,300,RC,9327189,CDM,,,,OUTPATIENT,,, 141.45, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 120.23,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46982,SM (SMITH) ANTIBODIES AND RNP (RIBONUCLEIC PROTEIN) ANTIBODIES TC,86235,HCPCS,300,RC,9332217,CDM,,,,OUTPATIENT,,, 141.45, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 120.23,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46983,SJOGREN'S SSA (RO) SSB (LA) ANTIBODIES TC,86235,HCPCS,300,RC,9332214,CDM,,,,OUTPATIENT,,, 141.62, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 120.38,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46984,PM/SCL-100 ANTIBODY IGG TC,86235,HCPCS,300,RC,9326303,CDM,,,,OUTPATIENT,,, 141.45, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 120.23,,OUTPCT LIMIT, 75.23,OTHER, 25.82, 138.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46985,PARANEOPLASTIC AB (PCCA/ANNA) BY IFA WITH REFLEX TO TITER AND IMMUNOBLOT TC,86255,HCPCS,300,RC,9313614,CDM,,,,OUTPATIENT,,, 120.85, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 102.72,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46986,SMOOTH MUSCLE AB TC,86255,HCPCS,300,RC,9332215,CDM,,,,OUTPATIENT,,, 112.66, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 95.76,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46987,ANTI-MITOCHONDRIAL TC,86255,HCPCS,300,RC,9312533,CDM,,,,OUTPATIENT,,, 159.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 135.15,,OUTPCT LIMIT, 68.02,OTHER, 17.35, 155.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46988,ENDOMYSIAL ABIGG TC,86256,HCPCS,300,RC,9275082,CDM,,,,OUTPATIENT,,, 243.17, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 206.69,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46989,NEURONAL NUCLEAR ANTIBODY (ANNA) TITER TC,86256,HCPCS,300,RC,9247096,CDM,,,,OUTPATIENT,,, 234.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 199.54,,OUTPCT LIMIT, 120.82,OTHER, 17.35, 238.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46990,DGP IGA TC,86258,HCPCS,300,RC,9261219,CDM,,,,OUTPATIENT,,, 25.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 21.25,,OUTPCT LIMIT, 15.65,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46991,CANCER ANTIGEN 15-3 BREAST TC,86300,HCPCS,300,RC,9255638,CDM,,,,OUTPATIENT,,, 149.04, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 126.68,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46992,CANCER ANTIGEN 27-29 TC,86300,HCPCS,300,RC,9255639,CDM,,,,OUTPATIENT,,, 153.24, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 130.25,,OUTPCT LIMIT, 80.94,OTHER, 29.96, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46993,CARBOHYDRATE ANTIGEN 19-9 (CA 19-9) SERUM,86301,HCPCS,300,RC,9258428,CDM,,,,OUTPATIENT,,, 159.71, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 135.75,,OUTPCT LIMIT, 85.12,OTHER, 29.96, 156.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46994,CANCER ANTIGEN 125 TC,86304,HCPCS,300,RC,9255630,CDM,,,,OUTPATIENT,,, 197.24, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 167.65,,OUTPCT LIMIT, 103.45,OTHER, 29.96, 193.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46995,LACTIC ACID (VENOUS),86305,HCPCS,300,RC,3454442,CDM,,,,OUTPATIENT,,, 135.30, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 115.01,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46996,HUMAN EPIDIDYMIS PROTEIN 4 (HE4) TC,86305,HCPCS,300,RC,9285846,CDM,,,,OUTPATIENT,,, 352.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 299.63,,OUTPCT LIMIT, 125.05,OTHER, 24.97, 345.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46997,MONO SCRN,86308,HCPCS,300,RC,633785,CDM,,,,OUTPATIENT,,, 99.86, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 84.88,,OUTPCT LIMIT, 50.54,OTHER, 7.46, 97.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46998,PHOSPHOLIP AB INTRP TC,86334,HCPCS,300,RC,9239003,CDM,,,,OUTPATIENT,,, 166.31, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 141.36,,OUTPCT LIMIT, 88.87,OTHER, 32.17, 162.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 46999,INSULIN ANTIBODIES TC,86337,HCPCS,300,RC,9292056,CDM,,,,OUTPATIENT,,, 121.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 102.85,,OUTPCT LIMIT, 66.43,OTHER, 30.83, 118.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47000,INTRINSIC FACTOR BLOCKING ANTIBODIES TC,86340,HCPCS,300,RC,9288477,CDM,,,,OUTPATIENT,,, 107.01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 90.96,,OUTPCT LIMIT, 57.43,OTHER, 21.72, 104.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47001,ISLET CELL ANTIBODIES IGG TC,86341,HCPCS,300,RC,9296761,CDM,,,,OUTPATIENT,,, 526.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 447.31,,OUTPCT LIMIT, 265.06,OTHER, 33.95, 515.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47002,CD3 CD4 AND CD8 TC,86356,HCPCS,300,RC,9258723,CDM,,,,OUTPATIENT,,, 147.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 124.95,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47003,MONOCLONAL PROTEIN SCREEN SERUM TC,86356,HCPCS,300,RC,9332219,CDM,,,,OUTPATIENT,,, 147.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 124.95,,OUTPCT LIMIT, 80.97,OTHER, 38.57, 144.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47004,86359 T CELL COUNT TOTAL,86359,HCPCS,300,RC,9647550,CDM,,,,OUTPATIENT,,, 202.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 172.13,,OUTPCT LIMIT, 111.82,OTHER, 54.34, 198.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47005,86360 T CELL ABSOLUTE COUNT/RATIO,86360,HCPCS,300,RC,9646172,CDM,,,,OUTPATIENT,,, 327.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 278.72,,OUTPCT LIMIT, 176.22,OTHER, 67.64, 321.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47006,CD3 CD4 AND CD8 TC ADDON,86361,HCPCS,300,RC,9654369,CDM,,,,OUTPATIENT,,, 161.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 137.28,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47007,CD4 TC,86361,HCPCS,300,RC,9255849,CDM,,,,OUTPATIENT,,, 161.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 137.28,,OUTPCT LIMIT, 88.05,OTHER, 38.57, 158.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47008,TTG IGA TC,86364,HCPCS,300,RC,9261221,CDM,,,,OUTPATIENT,,, 134.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 113.90,,OUTPCT LIMIT, 68.73,OTHER, 13.84, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47009,LIVER-KIDNEY MICROSOME 1 ANTIBODYIGG TC,86376,HCPCS,300,RC,9294636,CDM,,,,OUTPATIENT,,, 163.12, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 138.65,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47010,THYROID PEROXIDASE (TPO) ANTIBODIES TC,86376,HCPCS,300,RC,9333756,CDM,,,,OUTPATIENT,,, 210.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 178.50,,OUTPCT LIMIT, 96.09,OTHER, 20.95, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47011,TIS TRANSGLUT AB IGG TC,86384,HCPCS,300,RC,9239008,CDM,,,90,OUTPATIENT,,, 134.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 113.90,,OUTPCT LIMIT, 70.10,OTHER, 19.60, 131.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47012,RF IGA IGG AND IGM TC,86431,HCPCS,300,RC,9328413,CDM,,,,OUTPATIENT,,, 91.98, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 78.18,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47013,RHEUMATOID FACTOR,86431,HCPCS,300,RC,3454344,CDM,,,,OUTPATIENT,,, 91.98, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 78.18,,OUTPCT LIMIT, 46.86,OTHER, 8.16, 90.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47014,QUANTIFERON TB GOLD+ TC,86480,HCPCS,300,RC,9332259,CDM,,,,OUTPATIENT,,, 349.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 296.65,,OUTPCT LIMIT, 191.67,OTHER, 89.24, 342.02,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47015,PPD ADMINISTRATION POC,86580,HCPCS,521,RC,2562303,CDM,,,,OUTPATIENT,,, 18.70, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 15.90,,OUTPCT LIMIT, 12.31,OTHER, 8.04, 18.33,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47016,RPR TITER TC,86593,HCPCS,300,RC,9249964,CDM,,,,OUTPATIENT,,, 34.91, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 29.67,,OUTPCT LIMIT, 18.56,OTHER, 6.34, 34.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47017,ASPERGILLUS ANTIBODIES TC,86606,HCPCS,300,RC,9256474,CDM,,,,OUTPATIENT,,, 63.58, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 54.04,,OUTPCT LIMIT, 36.21,OTHER, 21.67, 62.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47018,BARTONELLA HENSELAE (CAT SCRATCH) ANTIBODIES IGG AND IGM TC,86611,HCPCS,300,RC,9255597,CDM,,,,OUTPATIENT,,, 106.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 90.10,,OUTPCT LIMIT, 55.25,OTHER, 14.66, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47019,BLASTOMYCES AB W/RFLX TC,86612,HCPCS,300,RC,9255603,CDM,,,,OUTPATIENT,,, 73.12, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 62.15,,OUTPCT LIMIT, 40.13,OTHER, 18.58, 71.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47020,BORDETELLA PERTUSSIS ANTIBODYIGG IGM IGA WITH REFLEXED IMMUNOBLOT TC,86615,HCPCS,300,RC,9258412,CDM,,,,OUTPATIENT,,, 127.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 107.95,,OUTPCT LIMIT, 66.54,OTHER, 19.00, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47021,BORRELIA BURGDORFERI BY PCR (LYME DISEASE) TC,86618,HCPCS,300,RC,9294645,CDM,,,,OUTPATIENT,,, 169.03, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 143.68,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47022,CD57 FOR CHRONIC LYME DISEASE (LYCD57) TC,86618,HCPCS,300,RC,9300134,CDM,,,,OUTPATIENT,,, 169.03, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 143.68,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47023,BORRELIA BURGDORFERI AB TC,86618,HCPCS,300,RC,9258411,CDM,,,,OUTPATIENT,,, 169.03, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 143.68,,OUTPCT LIMIT, 88.38,OTHER, 24.53, 165.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47024,CANDIDA SKIN TEST TC,86628,HCPCS,300,RC,9255838,CDM,,,,OUTPATIENT,,, 46.34, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 39.39,,OUTPCT LIMIT, 26.75,OTHER, 17.29, 45.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47025,COCCIDIOIDES ANTIBODIES PANEL SERUM (CF ID ELISA) TC,86635,HCPCS,300,RC,9271109,CDM,,,,OUTPATIENT,,, 96.93, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 82.39,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47026,COCCIDIOIDES ANTIBODIES IGG AND IGM TC,86635,HCPCS,300,RC,9272479,CDM,,,,OUTPATIENT,,, 260.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 221.00,,OUTPCT LIMIT, 91.08,OTHER, 16.51, 254.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47027,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG TC,86644,HCPCS,300,RC,9271096,CDM,,,,OUTPATIENT,,, 94.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 79.90,,OUTPCT LIMIT, 50.83,OTHER, 20.72, 92.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47028,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGM TC,86645,HCPCS,300,RC,9271101,CDM,,,,OUTPATIENT,,, 109.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 92.65,,OUTPCT LIMIT, 59.00,OTHER, 24.26, 106.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47029,ENA (EXTRACTABLE NUCLEAR ANTIGEN) ANTIBODIES TC,86664,HCPCS,300,RC,9275103,CDM,,,,OUTPATIENT,,, 121.26, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 103.07,,OUTPCT LIMIT, 64.46,OTHER, 22.02, 118.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47030,EPSTEIN-BARR VIRUS DNA QUANTITATIVE BY RAPID PCR TC,86665,HCPCS,300,RC,9273821,CDM,,,,OUTPATIENT,,, 109.11, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 92.74,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47031,EBV (EPSTEIN-BARR VIRUS) ANTIBODY PANEL TC,86665,HCPCS,300,RC,9275092,CDM,,,,OUTPATIENT,,, 109.11, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 92.74,,OUTPCT LIMIT, 59.50,OTHER, 26.12, 106.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47032,HELICOBACTER PYLORI ANTIGEN DETECTION TC,86677,HCPCS,300,RC,9285847,CDM,,,,OUTPATIENT,,, 182.98, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 155.53,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47033,H. PYLORI IGG,86677,HCPCS,300,RC,3454326,CDM,,,,OUTPATIENT,,, 110.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 93.61,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47034,HELICOBACTER PYLOR TOTAL ANTIBODY,86677,HCPCS,300,RC,9623240,CDM,,,,OUTPATIENT,,, 110.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 93.61,,OUTPCT LIMIT, 71.41,OTHER, 24.26, 179.32,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47035,HTLV I/II ABS BY ELISA WITH REFLEX TO HTLV I/II CONFIRMATION BY WESTERN BLOT TC,86689,HCPCS,300,RC,9286233,CDM,,,,OUTPATIENT,,, 123.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 104.55,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47036,HIV 1/2 AB CONFIRMATION TC,86689,HCPCS,300,RC,9249921,CDM,,,,OUTPATIENT,,, 123.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 104.55,,OUTPCT LIMIT, 66.70,OTHER, 27.86, 120.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47037,HSV 1 AND 2 (HERPES SIMPLEX VIRUS) ANTIBODIES IGM TC,86694,HCPCS,300,RC,9282714,CDM,,,,OUTPATIENT,,, 79.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 67.15,,OUTPCT LIMIT, 43.51,OTHER, 20.72, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47038,HERPESVIRUS 6 ANTIBODY IGG TC,86695,HCPCS,300,RC,9282670,CDM,,,,OUTPATIENT,,, 88.38, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 75.12,,OUTPCT LIMIT, 47.68,OTHER, 19.00, 86.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47039,HSV AB IGG I AND II TC,86696,HCPCS,300,RC,9285897,CDM,,,,OUTPATIENT,,, 106.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 90.10,,OUTPCT LIMIT, 58.39,OTHER, 27.86, 103.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47040,HISTOPLASMA AB CF/ID TC,86698,HCPCS,300,RC,9282673,CDM,,,,OUTPATIENT,,, 148.96, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 126.62,,OUTPCT LIMIT, 77.47,OTHER, 19.86, 145.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47041,HIV SCREEN TC,86703,HCPCS,300,RC,9285870,CDM,,,,OUTPATIENT,,, 118.37, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 100.61,,OUTPCT LIMIT, 62.50,OTHER, 19.74, 116.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47042,HEPATITIS B VIRUS CORE ANTIBODIES TOTAL TC,86704,HCPCS,300,RC,9285811,CDM,,,,OUTPATIENT,,, 87.27, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 74.18,,OUTPCT LIMIT, 46.75,OTHER, 17.35, 85.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47043,HEPATITIS B VIRUS CORE ANTIBODIES IGM TC,86705,HCPCS,300,RC,9282628,CDM,,,,OUTPATIENT,,, 76.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 64.60,,OUTPCT LIMIT, 41.14,OTHER, 16.94, 74.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47044,HEPATITIS B VIRUS SURFACE ANTIBODIES TITER TC,86706,HCPCS,300,RC,9282630,CDM,,,,OUTPATIENT,,, 129.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 110.36,,OUTPCT LIMIT, 67.08,OTHER, 15.47, 127.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47045,HEPATITIS A VIRUS ANTIBODIES TOTAL TC,86708,HCPCS,300,RC,9282586,CDM,,,,OUTPATIENT,,, 94.77, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 80.55,,OUTPCT LIMIT, 50.52,OTHER, 17.84, 92.87,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47046,HEPATITIS A VIRUS ANTIBODIES IGM TC,86709,HCPCS,300,RC,9282587,CDM,,,,OUTPATIENT,,, 49.80, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 42.33,,OUTPCT LIMIT, 28.18,OTHER, 16.21, 48.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47047,MUMPS IGG AB TC,86735,HCPCS,300,RC,9312684,CDM,,,,OUTPATIENT,,, 98.44, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 83.67,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47048,MUMPS VIRUS ANTIBODIES IGG TC,86735,HCPCS,300,RC,9311075,CDM,,,,OUTPATIENT,,, 98.44, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 83.67,,OUTPCT LIMIT, 52.54,OTHER, 18.79, 96.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47049,MYCOPLASMA IGG/IGM TC,86738,HCPCS,300,RC,9311077,CDM,,,,OUTPATIENT,,, 75.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 63.75,,OUTPCT LIMIT, 41.16,OTHER, 19.07, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47050,RUBELLA SCREEN (IGG) TC,86762,HCPCS,300,RC,9637502,CDM,,,,OUTPATIENT,,, 84.33, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 71.68,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47051,RUBELLA ABIGM TC,86762,HCPCS,300,RC,9329231,CDM,,,,OUTPATIENT,,, 84.33, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 71.68,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47052,RUBELLA ANTIBODIES IGG TC,86762,HCPCS,300,RC,9327182,CDM,,,,OUTPATIENT,,, 84.33, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 71.68,,OUTPCT LIMIT, 46.11,OTHER, 20.72, 82.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47053,RUBEOLA (MEASLES) ANTIBODIES IGM TC,86765,HCPCS,300,RC,9329230,CDM,,,,OUTPATIENT,,, 87.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 74.16,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47054,RUBEOLA (MEASLES) ANTIBODIES IGG TC,86765,HCPCS,300,RC,9327176,CDM,,,,OUTPATIENT,,, 90.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 76.71,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47055,RUBEOLA IGG TC,86765,HCPCS,300,RC,9312685,CDM,,,,OUTPATIENT,,, 90.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 76.71,,OUTPCT LIMIT, 48.00,OTHER, 18.55, 88.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47056,TREPONEMA PALLIDUM ANTIBODIES TC,86780,HCPCS,300,RC,9333755,CDM,,,,OUTPATIENT,,, 91.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 78.06,,OUTPCT LIMIT, 49.38,OTHER, 19.07, 89.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47057,VARICELLA-ZOSTER VIRUS ANTIBODIES IGM TC,86787,HCPCS,300,RC,9337200,CDM,,,,OUTPATIENT,,, 155.01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 131.76,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47058,VARICELLA-ZOSTER VIRUS ANTIBODIES IGG TC,86787,HCPCS,300,RC,9337201,CDM,,,,OUTPATIENT,,, 155.01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 131.76,,OUTPCT LIMIT, 80.11,OTHER, 18.55, 151.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47059,HANTAVIRUS ANTIBODIES (IGG IGM) TC,86790,HCPCS,300,RC,9285809,CDM,,,,OUTPATIENT,,, 731.79, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 622.02,,OUTPCT LIMIT, 361.76,OTHER, 18.55, 717.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47060,HEPATITIS C VIRUS ANTIBODIES TC,86803,HCPCS,300,RC,9285843,CDM,,,,OUTPATIENT,,, 321.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 272.85,,OUTPCT LIMIT, 161.64,OTHER, 20.54, 314.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47061,POST TRANSPLANT ANTIBODY WORKUP BY LUMINEX TC,86828,HCPCS,300,RC,9282675,CDM,,,,OUTPATIENT,,, 279.77, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 237.80,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47062,HLA B27 TC,86828,HCPCS,300,RC,9285875,CDM,,,,OUTPATIENT,,, 279.77, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 237.80,,OUTPCT LIMIT, 158.63,OTHER, 92.44, 274.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47063,ANTIBODY SCREEN TUBE,86850,HCPCS,300,RC,634329,CDM,,,,OUTPATIENT,,, 152.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 129.97,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47064,ANTIBODY SCREEN GEL,86850,HCPCS,300,RC,7032166,CDM,,,,OUTPATIENT,,, 152.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 129.97,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47065,REF ABSC,86850,HCPCS,300,RC,8082500,CDM,,,,OUTPATIENT,,, 152.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 129.97,,OUTPCT LIMIT, 78.01,OTHER, 14.06, 149.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47066,REF ELUTION,86860,HCPCS,300,RC,8211739,CDM,,,,OUTPATIENT,,, 239.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 203.15,,OUTPCT LIMIT, 152.44,OTHER, 102.77, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47067,BILL ONLY ABID PANEL,86870,HCPCS,300,RC,8044257,CDM,,,,OUTPATIENT,,, 430.86, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 366.23,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47068,REF ANTIBODY ID,86870,HCPCS,300,RC,7032173,CDM,,,,OUTPATIENT,,, 430.86, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 366.23,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47069,ANTIBODY IDENTIFICATION RBC (BLOOD BANK) TC,86870,HCPCS,300,RC,9256486,CDM,,,,OUTPATIENT,,, 430.86, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 366.23,,OUTPCT LIMIT, 270.23,OTHER, 185.27, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47070,REF DAT IGG,86880,HCPCS,300,RC,8090680,CDM,,,,OUTPATIENT,,, 163.66, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 139.11,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47071,REF DAT C3,86880,HCPCS,300,RC,8090679,CDM,,,,OUTPATIENT,,, 163.66, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 139.11,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47072,DAT IGG/C3,86880,HCPCS,300,RC,1173771,CDM,,,,OUTPATIENT,,, 163.66, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 139.11,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47073,CORD DAT,86880,HCPCS,300,RC,7032169,CDM,,,,OUTPATIENT,,, 163.66, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 139.11,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47074,REF DAT POLY,86880,HCPCS,300,RC,8090681,CDM,,,,OUTPATIENT,,, 163.66, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 139.11,,OUTPCT LIMIT, 81.76,OTHER, 7.76, 160.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47075,ANTIBODY TITER RBC (BLOOD BANK) TC,86886,HCPCS,300,RC,9258409,CDM,,,,OUTPATIENT,,, 297.11, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 252.54,,OUTPCT LIMIT, 146.86,OTHER, 7.46, 291.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47076,CORD ABO/RH,86900,HCPCS,300,RC,7032168,CDM,,,,OUTPATIENT,,, 110.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 93.50,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47077,ABO/RH,86900,HCPCS,300,RC,634326,CDM,,,,OUTPATIENT,,, 110.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 93.50,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47078,REF ABO/RH,86900,HCPCS,300,RC,8058897,CDM,,,,OUTPATIENT,,, 110.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 93.50,,OUTPCT LIMIT, 54.74,OTHER, 4.31, 107.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47079,RH RETYPE,86901,HCPCS,300,RC,9545503,CDM,,,,OUTPATIENT,,, 91.08, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 77.42,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47080,REF RH,86901,HCPCS,300,RC,9545504,CDM,,,,OUTPATIENT,,, 86.56, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.58,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47081,RH TYPING,86901,HCPCS,300,RC,9544516,CDM,,,,OUTPATIENT,,, 91.08, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 77.42,,OUTPCT LIMIT, 44.77,OTHER, 4.31, 89.26,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47082,BILL ONLY AG TYPING MAJOR AG,86905,HCPCS,300,RC,9327162,CDM,,,,OUTPATIENT,,, 430.86, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 366.23,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47083,BILL ONLY AG TYPING UNUSUAL/RARE,86905,HCPCS,300,RC,9327163,CDM,,,,OUTPATIENT,,, 430.86, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 366.23,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47084,REF EXTENDED PHENOTYPE,86905,HCPCS,300,RC,9561121,CDM,,,,OUTPATIENT,,, 391.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 332.78,,OUTPCT LIMIT, 205.30,OTHER, 5.52, 422.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47085,BILL ONLY AG TYPING FULL PHENOTYPE,86906,HCPCS,300,RC,9327164,CDM,,,,OUTPATIENT,,, 139.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 118.58,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47086,REF RH PHENOTYPE,86906,HCPCS,300,RC,8745502,CDM,,,,OUTPATIENT,,, 139.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 118.58,,OUTPCT LIMIT, 70.78,OTHER, 11.16, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47087,XM AHG GEL INTERP -> INCOMPATIBLE,86922,HCPCS,300,RC,8048056,CDM,,,,OUTPATIENT,,, 594.22, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 505.09,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47088,XM AHG GEL INTERP -> COMPATIBLE,86922,HCPCS,300,RC,8048057,CDM,,,,OUTPATIENT,,, 594.22, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 505.09,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47089,SEROLOGICAL IMMEDIATE SPIN -> COMPATIBLE,86922,HCPCS,300,RC,8048063,CDM,,,,OUTPATIENT,,, 594.22, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 505.09,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47090,REF CROSSMATCH,86922,HCPCS,300,RC,9321278,CDM,,,,OUTPATIENT,,, 594.22, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 505.09,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47091,XM AHG GEL INTERP -> LEAST INCOMPATIBLE,86922,HCPCS,300,RC,8048055,CDM,,,,OUTPATIENT,,, 594.22, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 505.09,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47092,SEROLOGICAL IMMEDIATE SPIN -> INCOMPATIBLE,86922,HCPCS,300,RC,8048061,CDM,,,,OUTPATIENT,,, 594.22, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 505.09,,OUTPCT LIMIT, 325.90,OTHER, 150.08, 582.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47093,BILL ONLY RBC TREAT,86970,HCPCS,300,RC,9559883,CDM,,,,OUTPATIENT,,, 139.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 118.58,,OUTPCT LIMIT, 76.50,OTHER, 35.20, 136.71,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47094,BILL ONLY ABSORPTION,86978,HCPCS,300,RC,9179149,CDM,,,,OUTPATIENT,,, 261.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 221.85,,OUTPCT LIMIT, 149.18,OTHER, 91.25, 255.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47095,BLOOD CULTURE BACTERIA AND YEAST - 2ND SET TC,87040,HCPCS,300,RC,9304146,CDM,,,,OUTPATIENT,,, 159.46, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 135.54,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47096,BLOOD CULTURE BACTERIA AND YEAST TC,87040,HCPCS,300,RC,9258721,CDM,,,,OUTPATIENT,,, 159.46, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 135.54,,OUTPCT LIMIT, 81.41,OTHER, 14.86, 156.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47097,SPECIAL STOOL CULTURE TC,87046,HCPCS,300,RC,9272751,CDM,,,,OUTPATIENT,,, 56.37, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 47.91,,OUTPCT LIMIT, 30.76,OTHER, 13.60, 55.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47098,CATHETER TIP CULTURE SEMIQUANTITATIVE ADDON,87070,HCPCS,300,RC,9704890,CDM,,,,OUTPATIENT,,, 142.70, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 121.30,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47099,CATHETER TIP CULTURE SEMIQUANTITATIVE TC,87070,HCPCS,300,RC,9274098,CDM,,,,OUTPATIENT,,, 142.70, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 121.30,,OUTPCT LIMIT, 72.64,OTHER, 12.41, 139.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47100,AEROBIC/ANAEROBIC CULTURE SWAB TC,87075,HCPCS,300,RC,9275049,CDM,,,,OUTPATIENT,,, 153.62, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 130.58,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47101,AEROBIC/ANAEROBIC CULTURE ADDON,87075,HCPCS,300,RC,9704895,CDM,,,,OUTPATIENT,,, 153.62, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 130.58,,OUTPCT LIMIT, 78.26,OTHER, 13.63, 150.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47102,BILL ONLY 87076 ANAEROBE DEFINITIVE ID,87076,HCPCS,300,RC,9612122,CDM,,,,OUTPATIENT,,, 156.09, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 132.68,,OUTPCT LIMIT, 78.99,OTHER, 11.64, 152.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47103,CULTURE AEROBIC IDENTIFY - 87077,87077,HCPCS,300,RC,9051083,CDM,,,,OUTPATIENT,,, 90.11, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 76.59,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47104,AEROBE DEFINITIVE ID,87077,HCPCS,300,RC,9612121,CDM,,,,OUTPATIENT,,, 90.11, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 76.59,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47105,RAPID UREASE TEST TC,87077,HCPCS,300,RC,9329249,CDM,,,,OUTPATIENT,,, 90.11, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 76.59,,OUTPCT LIMIT, 46.77,OTHER, 11.64, 88.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47106,NEISSERIA GONORRHOEAE CULTURE TC,87081,HCPCS,300,RC,9261178,CDM,,,,OUTPATIENT,,, 79.23, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 67.35,,OUTPCT LIMIT, 40.96,OTHER, 9.55, 77.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47107,URINE CULTURE TC,87086,HCPCS,300,RC,9275048,CDM,,,,OUTPATIENT,,, 85.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.96,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47108,URINE CULTURE CHARGE TC -> COL COUNT,87086,HCPCS,300,RC,9601900,CDM,,,,OUTPATIENT,,, 85.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.96,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47109,87086 URINE CULTURE COLONY COUNT,87086,HCPCS,300,RC,9719968,CDM,,,,OUTPATIENT,,, 85.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.96,,OUTPCT LIMIT, 44.68,OTHER, 11.62, 84.11,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47110,87088 URINE PRESUMPTIVE ID,87088,HCPCS,300,RC,9719969,CDM,,,,OUTPATIENT,,, 162.78, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 138.36,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47111,URINE CULTURE CHARGE TC -> PRES ID,87088,HCPCS,300,RC,9601899,CDM,,,,OUTPATIENT,,, 162.78, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 138.36,,OUTPCT LIMIT, 82.26,OTHER, 11.65, 159.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47112,FUNGUS CULTURE TC,87102,HCPCS,300,RC,9261177,CDM,,,,OUTPATIENT,,, 147.16, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 125.09,,OUTPCT LIMIT, 74.74,OTHER, 12.11, 144.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47113,BLOOD CULTURE AFB (ACID FAST BACILLI) AND FUNGUS TC,87116,HCPCS,300,RC,9305705,CDM,,,,OUTPATIENT,,, 178.78, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 151.96,,OUTPCT LIMIT, 91.00,OTHER, 15.55, 175.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47114,OVA AND PARASITESTOOL (MICROSCOPIC EXAM) TC,87177,HCPCS,300,RC,9325947,CDM,,,,OUTPATIENT,,, 133.64, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 113.59,,OUTPCT LIMIT, 68.31,OTHER, 12.82, 130.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47115,SUSCEPTIBILITY TESTING ONLY TC,87181,HCPCS,300,RC,9272736,CDM,,,,OUTPATIENT,,, 33.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 28.05,,OUTPCT LIMIT, 17.74,OTHER, 6.84, 32.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47116,SUSCEPTIBILITY TC,87184,HCPCS,300,RC,9255005,CDM,,,,OUTPATIENT,,, 41.83, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 35.56,,OUTPCT LIMIT, 22.99,OTHER, 10.78, 40.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47117,ANGIOTENSION CONVERTING ENZYME (ACE) TC,87185,HCPCS,300,RC,9255587,CDM,,,,OUTPATIENT,,, 58.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 49.30,,OUTPCT LIMIT, 29.95,OTHER, 6.84, 56.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47118,SENSITIVITY,87186,HCPCS,300,RC,9612120,CDM,,,,OUTPATIENT,,, 80.78, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 68.66,,OUTPCT LIMIT, 42.41,OTHER, 12.46, 79.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47119,GRAM STAIN GL,87205,HCPCS,300,RC,8092241,CDM,,,,OUTPATIENT,,, 56.59, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 48.10,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47120,SPUTUM CULTURE TC ADDON,87205,HCPCS,300,RC,9698596,CDM,,,,OUTPATIENT,,, 52.69, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 44.79,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47121,SPUTUM CULTURE TC,87205,HCPCS,300,RC,9274078,CDM,,,,OUTPATIENT,,, 52.69, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 44.79,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47122,GRAM STAIN ADDON,87205,HCPCS,300,RC,9705827,CDM,,,,OUTPATIENT,,, 52.89, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 44.96,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47123,GRAM STAIN TC,87205,HCPCS,300,RC,9282584,CDM,,,,OUTPATIENT,,, 52.89, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 44.96,,OUTPCT LIMIT, 27.61,OTHER, 6.14, 55.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47124,AFB (ACID FAST BACILLI) CULTURE TC,87206,HCPCS,300,RC,9258427,CDM,,,,OUTPATIENT,,, 74.33, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 63.18,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47125,AFB STAIN ONLY TC,87206,HCPCS,300,RC,9249329,CDM,,,,OUTPATIENT,,, 74.33, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 63.18,,OUTPCT LIMIT, 38.14,OTHER, 7.76, 72.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47126,TRICH PREP,87210,HCPCS,300,RC,633915,CDM,,,,OUTPATIENT,,, 53.85, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 45.77,,OUTPCT LIMIT, 28.29,OTHER, 8.38, 52.77,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47127,GI VIRAL PANEL TC,87254,HCPCS,300,RC,9282585,CDM,,,,OUTPATIENT,,, 127.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 107.95,,OUTPCT LIMIT, 68.72,OTHER, 28.16, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47128,RAPID C. DIFFICILE TC,87324,HCPCS,300,RC,9255850,CDM,,,,OUTPATIENT,,, 604.70, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 514.00,,OUTPCT LIMIT, 299.39,OTHER, 17.26, 592.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47129,HEPATITIS B VIRUS SURFACE ANTIGEN TC,87340,HCPCS,300,RC,9282631,CDM,,,,OUTPATIENT,,, 76.02, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 64.62,,OUTPCT LIMIT, 40.67,OTHER, 14.88, 74.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47130,HEPATITIS BE VIRUS ANTIBODIES TC,87350,HCPCS,300,RC,9285812,CDM,,,,OUTPATIENT,,, 80.12, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 68.10,,OUTPCT LIMIT, 43.08,OTHER, 16.61, 78.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47131,HISTOPLASMA GALACTOMANNAN ANTIGEN QUANTITATIVE BY EIA URINE TC,87385,HCPCS,300,RC,9348219,CDM,,,,OUTPATIENT,,, 239.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 203.15,,OUTPCT LIMIT, 121.25,OTHER, 19.08, 234.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47132,VAGINAL PANEL BY NAA TC,87480,HCPCS,300,RC,9337160,CDM,,,,OUTPATIENT,,, 127.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 107.95,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47133,CHLAMYDIA ANTIBODY PANELIGG IGM BY IFA TC,87491,HCPCS,300,RC,9261188,CDM,,,,OUTPATIENT,,, 193.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 164.05,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47134,CHLAMYDIA/GC AMP TC,87491,HCPCS,300,RC,9332221,CDM,,,,OUTPATIENT,,, 193.01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 164.06,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47135,CLOSTRIDIUM DIFFICILE ANTIGEN,87493,HCPCS,300,RC,8367476,CDM,,,,OUTPATIENT,,, 193.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 164.05,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47136,C. DIFFICILE BY PCR TC,87493,HCPCS,300,RC,9275913,CDM,,,,OUTPATIENT,,, 193.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 164.05,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47137,C DIFF TOX,87493,HCPCS,300,RC,7934630,CDM,,,,OUTPATIENT,,, 193.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 164.05,,OUTPCT LIMIT, 107.02,OTHER, 53.66, 189.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47138,CMV (CYTOMEGALOVIRUS) ANTIBODIES IGG AND IGM TC,87497,HCPCS,300,RC,9271099,CDM,,,,OUTPATIENT,,, 377.15, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 320.58,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47139,CMV (CYTOMEGALOVIRUS) QUANTITATIVE PCR TC,87497,HCPCS,300,RC,9271102,CDM,,,,OUTPATIENT,,, 377.15, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 320.58,,OUTPCT LIMIT, 198.86,OTHER, 61.69, 369.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47140,FECAL PATHOGENS PCR TC,87505,HCPCS,300,RC,9332222,CDM,,,,OUTPATIENT,,, 157.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 133.56,,OUTPCT LIMIT, 100.71,OTHER, 67.57, 153.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47141,HEPATITIS C QUANTITATIVE BY REAL TIME PCR TC,87522,HCPCS,300,RC,9285844,CDM,,,,OUTPATIENT,,, 423.47, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 359.95,,OUTPCT LIMIT, 221.47,OTHER, 61.69, 415.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47142,HSV1/HSV2 SUBTYPE PCR TC,87529,HCPCS,300,RC,9286239,CDM,,,,OUTPATIENT,,, 131.89, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 112.11,,OUTPCT LIMIT, 76.43,OTHER, 50.53, 129.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47143,HIV 1 (HUMAN IMMUNODEFICIENCY VIRUS) BY RT PCR QUANTITATIVE (VIRAL LOAD) TC,87536,HCPCS,300,RC,9285874,CDM,,,,OUTPATIENT,,, 483.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 410.55,,OUTPCT LIMIT, 265.03,OTHER, 122.54, 473.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47144,CHLAMYDIA/GC AMP TC ADDON,87591,HCPCS,300,RC,9652407,CDM,,,,OUTPATIENT,,, 193.01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 164.06,,OUTPCT LIMIT, 106.28,OTHER, 50.53, 189.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47145,HPV HIGH RISK TC,87624,HCPCS,300,RC,9285883,CDM,,,,OUTPATIENT,,, 150.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 127.50,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47146,HPVHR PCRSUREPATH TC,87624,HCPCS,300,RC,9285884,CDM,,,,OUTPATIENT,,, 150.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 127.50,,OUTPCT LIMIT, 96.14,OTHER, 64.50, 147.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47147,RESPIRATORY VIRUS PANEL PCR TC,87633,HCPCS,300,RC,9321439,CDM,,,,OUTPATIENT,,, 620.06, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 527.05,,OUTPCT LIMIT, 445.68,OTHER, 266.63, 607.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47148,SARS-COV-2 (COVID-19) AG,87635,HCPCS,300,RC,8516840,CDM,,,,OUTPATIENT,,, 100.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 85.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47149,SARS-COV-2 NAA LC,87635,HCPCS,300,RC,8186970,CDM,,,,OUTPATIENT,,, 100.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 85.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47150,SARS COV-2(COVID-19) AG,87635,HCPCS,300,RC,8516838,CDM,,,,OUTPATIENT,,, 100.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 85.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47151,NASAL MRSA CARRIAGE TC,87641,HCPCS,300,RC,9329225,CDM,,,,OUTPATIENT,,, 372.62, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 316.73,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47152,MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS) SURVEILLANCE SCREEN TC,87641,HCPCS,300,RC,9271083,CDM,,,,OUTPATIENT,,, 372.62, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 316.73,,OUTPCT LIMIT, 193.99,OTHER, 50.53, 365.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47153,GRP ACG STREP BY NAA TC,87650,HCPCS,300,RC,9282560,CDM,,,,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47154,STREPTOCOCCUS CULTURE SPECIAL TC,87651,HCPCS,300,RC,9274088,CDM,,,,OUTPATIENT,,, 331.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 281.35,,OUTPCT LIMIT, 173.66,OTHER, 50.53, 324.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47155,TRICH VAGINALIS NAAT TC,87660,HCPCS,300,RC,9338241,CDM,,,,OUTPATIENT,,, 127.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 107.95,,OUTPCT LIMIT, 68.89,OTHER, 28.87, 124.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47156,VARICELLA ZOSTER VIRUS BY PCR TC,87798,HCPCS,300,RC,9338787,CDM,,,,OUTPATIENT,,, 175.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 148.92,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47157,NOROVIRUS GRP1AND2 TC,87798,HCPCS,300,RC,9319372,CDM,,,,OUTPATIENT,,, 611.94, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 520.15,,OUTPCT LIMIT, 204.22,OTHER, 50.53, 599.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47158,BK VIRUS QUANTITATIONREAL TIME PCR TC,87799,HCPCS,300,RC,9255031,CDM,,,,OUTPATIENT,,, 269.97, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 229.47,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47159,BK VIRUS QUANTITATIVE PCR URINE TC,87799,HCPCS,300,RC,9337153,CDM,,,,OUTPATIENT,,, 269.97, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 229.47,,OUTPCT LIMIT, 146.52,OTHER, 61.69, 264.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47160,FLU AANDB,87804,HCPCS,300,RC,8057356,CDM,,,,OUTPATIENT,,, 115.87, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 98.49,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47161,INFLUENZA A/B CLINIC POC (RE),87804,HCPCS,521,RC,8198028,CDM,,,,OUTPATIENT,,, 115.87, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 98.49,,OUTPCT LIMIT, 62.25,OTHER, 23.83, 113.55,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47162,RSV,87807,HCPCS,300,RC,8045351,CDM,,,,OUTPATIENT,,, 79.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 67.15,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47163,RSV POC (RE),87807,HCPCS,300,RC,8196157,CDM,,,,OUTPATIENT,,, 79.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 67.15,,OUTPCT LIMIT, 43.07,OTHER, 18.86, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47164,STREP A,87880,HCPCS,300,RC,8045352,CDM,,,,OUTPATIENT,,, 79.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 67.15,,OUTPCT LIMIT, 44.25,OTHER, 23.81, 77.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47165,RAPID STREP CLINIC POC (RE),87880,HCPCS,521,RC,8198036,CDM,,,,OUTPATIENT,,, 25.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 21.25,,OUTPCT LIMIT, 17.88,OTHER, 10.75, 24.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47166,CRYPTOCOCCAL ANTIGEN SERUM TC,87899,HCPCS,300,RC,9272733,CDM,,,,OUTPATIENT,,, 193.79, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 164.72,,OUTPCT LIMIT, 100.14,OTHER, 23.14, 189.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47167,HIV (HUMAN IMMUNODEFICIENCY VIRUS) GENOTYPE TC,87901,HCPCS,300,RC,9282674,CDM,,,,OUTPATIENT,,, 1459.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1240.15,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47168,HEPATITIS C VIRUS GENOTYPE TC,87902,HCPCS,300,RC,9285819,CDM,,,,OUTPATIENT,,, 1459.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1240.15,,OUTPCT LIMIT, 800.72,OTHER, 370.73, 1429.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47169,HYDROXYPROGESTERONE (17-HYDROXYPROGESTERONE) TC,88175,HCPCS,300,RC,9285881,CDM,,,,OUTPATIENT,,, 104.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 88.40,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47170,PAP SMEAR TC,88175,HCPCS,310,RC,9319388,CDM,,,,OUTPATIENT,,, 104.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 88.40,,OUTPCT LIMIT, 59.91,OTHER, 38.32, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47171,FLOW LEUKEMIA PANEL TC,88184,HCPCS,310,RC,9279308,CDM,,,,OUTPATIENT,,, 555.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 471.75,,OUTPCT LIMIT, 294.34,OTHER, 97.97, 543.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47172,SPECIMEN FOR PATHOLOGY CONSULT SERVICES TC,88302,HCPCS,300,RC,9271112,CDM,,,,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47173,DERMATOPATHOLOGY TC,88302,HCPCS,300,RC,9275054,CDM,,,,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47174,BF CELL CT,89050,HCPCS,300,RC,8231372,CDM,,,,OUTPATIENT,,, 31.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 26.35,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47175,CELL COUNT BODY FLUID TC,89050,HCPCS,300,RC,9284839,CDM,,,,OUTPATIENT,,, 31.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 26.35,,OUTPCT LIMIT, 16.75,OTHER, 6.79, 30.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47176,CELL COUNT CSF TC,89051,HCPCS,300,RC,9327208,CDM,,,,OUTPATIENT,,, 112.41, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 95.55,,OUTPCT LIMIT, 56.81,OTHER, 8.06, 110.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47177,CRYSTALS SYNOVIAL/JOINT FLUID TC,89060,HCPCS,300,RC,9284841,CDM,,,,OUTPATIENT,,, 76.72, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 65.21,,OUTPCT LIMIT, 39.98,OTHER, 10.56, 75.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47178,POST VAS,89321,HCPCS,300,RC,3454457,CDM,,,,OUTPATIENT,,, 77.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 65.45,,OUTPCT LIMIT, 41.73,OTHER, 17.35, 75.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47179,AMB RABIES IMMUNE GLOBULIN HUMAN CHARGE -> RABIES IMMUNE GLOBULIN HUMAN,90377,HCPCS,250,RC,9580821,CDM,,,,BOTH,1,EA, 5932.43, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 5042.57,,OUTPCT LIMIT, 3802.17,OTHER, 2550.94, 5813.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47180,ADMIN IMMUNIZATION CHARGE -> FIRST VACCINE 90471,90471,HCPCS,771,RC,9817486,CDM,,,,OUTPATIENT,,, 112.66, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 95.76,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47181,90471 MANUAL CHARGE FIRST VACCINE AMB ADMIN CHARGE 19 AND <,90471,HCPCS,771,RC,9562127,CDM,,,,OUTPATIENT,,, 112.66, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 95.76,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47182,ADMIN IMMUNIZATION CHARGE -> EACH ADDITIONAL 90472,90472,HCPCS,521,RC,9816191,CDM,,,,OUTPATIENT,,, 29.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 25.08,,OUTPCT LIMIT, 23.30,OTHER, 12.69, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47183,90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE FIRST VACCINE,90473,HCPCS,521,RC,8044708,CDM,,,,OUTPATIENT,,, 59.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 50.58,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47184,90474 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE EA ADDTL,90474,HCPCS,521,RC,8213665,CDM,,,,OUTPATIENT,,, 29.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 25.29,,OUTPCT LIMIT, 23.42,OTHER, 12.79, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47185,90632 HEPATITIS A VACCINE ADULT DOSAGE FOR INTRAMUSCULAR USE,90632,HCPCS,636,RC,8044709,CDM,,,,BOTH,1,EA, 129.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 109.65,,OUTPCT LIMIT, 82.68,OTHER, 55.47, 126.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47186,AMB HEPATITIS A PEDIATRIC CHARGE -> VACCINE HEP A (VAQTA),90633,HCPCS,250,RC,8554891,CDM,,,,BOTH,1,EA, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47187,AMB HUMAN PAPILLOMAVIRUS CHARGE -> HPV9 (GARDASIL 9) 90651,90651,HCPCS,636,RC,8555123,CDM,,,,BOTH,1,EA, 153.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 130.05,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47188,90651 GARDASIL 9 HPV VACCINE,90651,HCPCS,636,RC,8044714,CDM,,,,BOTH,1,EA, 153.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 130.05,,OUTPCT LIMIT, 149.84,OTHER, 65.79, 315.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47189,90653 INFLUENZA VACCINE INACTIVATED (IIV) SUBUNIT ADJUVANTED FOR INTRAMUSCULAR,90653,HCPCS,636,RC,8106144,CDM,,,,BOTH,1,EA, 138.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 118.11,,OUTPCT LIMIT, 89.06,OTHER, 59.75, 136.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47190,AMB INFLUENZA CHARGE -> FLUZONE HIGH-DOSE,90662,HCPCS,636,RC,8696702,CDM,,,,BOTH,1,EA, 50.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 42.50,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47191,90662 FLUZONE HIGH DOSE SYR >/= 65 YEARS,90662,HCPCS,636,RC,8581457,CDM,,,,BOTH,1,EA, 50.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 42.50,,OUTPCT LIMIT, 41.40,OTHER, 21.50, 71.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47192,90670 DO NOT USE PREVNAR 13PNEUMOCOCCAL CONJUGATE VACCINE 13 VALENT,90670,HCPCS,636,RC,8044716,CDM,,,,BOTH,1,EA, 593.39, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 504.38,,OUTPCT LIMIT, 356.50,OTHER, 255.16, 581.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47193,AMB RABIES VACCINE CHARGE -> 1 ML RABIES,90675,HCPCS,250,RC,9279578,CDM,,,,BOTH,1,ML, 1239.79, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1053.82,,OUTPCT LIMIT, 687.64,OTHER, 345.38, 1214.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47194,AMB PNEUMOCOCCAL 20VALENT VACCINE CHARGE VACCINE PNEUMOCOCCAL 20 VALENT,90677,HCPCS,636,RC,8627820,CDM,,,,BOTH,1,EA, 314.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 267.33,,OUTPCT LIMIT, 201.57,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47195,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 1 ML ORAL VACCINE ROTAVIRUS (ROTARIX),90680,HCPCS,636,RC,8554675,CDM,,,,BOTH,1,ML, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47196,AMB ROTAVIRUS ORAL VACCINE CHARGE -> 2 ML ORAL VACCINE ROTAVIRUS (ROTATEQ),90680,HCPCS,636,RC,8554674,CDM,,,,BOTH,2,ML, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47197,AMB INFLUENZA CHARGE -> FLUBLOK EGG FREE˙0.5ML,90682,HCPCS,250,RC,8927349,CDM,,,,BOTH,.5,ML, 85.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.25,,OUTPCT LIMIT, 60.00,OTHER, 36.55, 83.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47198,AMB INFLUENZA CHARGE -> AFLURIA - SINGLE DOSE,90686,HCPCS,636,RC,8752088,CDM,,,,BOTH,1,EA, 51.45, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 43.73,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47199,90686 DO NOT USE FLULAVAL-INFLU VIRUS VAC QUAD (IIV4) SPLIT VIRUS 0.5 ML,90686,HCPCS,636,RC,8044719,CDM,,,,BOTH,.5,ML, 51.45, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 43.73,,OUTPCT LIMIT, 36.74,OTHER, 22.12, 50.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47200,AMB DIPHTHERIA/PERTUSSIS/POLIO/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS,90696,HCPCS,250,RC,8554714,CDM,,,,BOTH,.5,ML, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47201,AMB DIPHTHERIA/PERTUSSIS/TETANUS CHARGE -> 0.5 ML DIPHTHERIA/PERTUSSIS/TETANUS,90697,HCPCS,250,RC,9080254,CDM,,,,BOTH,.5,ML, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47202,AMB DTAP/IPV/HIB CHARGE -> 0.5 ML DTAP/IPV/HIB VACCINE,90698,HCPCS,636,RC,8937645,CDM,,,,BOTH,.5,ML, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47203,AMB MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE CHARGE -> 3ML MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8719683,CDM,,,,BOTH,3,ML, 11.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 9.35,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47204,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> VACCINE MEASLES-MUMPS-RUBELLA,90707,HCPCS,636,RC,8548398,CDM,,,,BOTH,1,EA, 11.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 9.35,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47205,AMB MEASLES-MUMPS-RUBELLA VACCINE CHARGE -> CHDP MEASLES MUMPS RUBELLA,90707,HCPCS,636,RC,8548399,CDM,,,,BOTH,1,EA, 11.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 9.35,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47206,90707 MEASLES MUMPS AND RUBELLA VIRUS VACCINE (MMR) LIVE FOR SUBCUTANEOUS USE,90707,HCPCS,636,RC,8044724,CDM,,,,BOTH,1,EA, 11.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 9.35,,OUTPCT LIMIT, 7.05,OTHER, 4.73, 10.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47207,90714 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD) PRESERVATIVE FREE,90714,HCPCS,636,RC,8139739,CDM,,,,BOTH,1,EA, 79.74, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 67.78,,OUTPCT LIMIT, 51.11,OTHER, 34.29, 78.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47208,AMB TDAP CHARGE -> DTAP 90700,90715,HCPCS,636,RC,9574503,CDM,,,,BOTH,1,EA, 136.71, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 116.20,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47209,90715 BOOSTRIX-TETANUS DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VAC,90715,HCPCS,636,RC,8044725,CDM,,,,BOTH,1,EA, 136.71, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 116.20,,OUTPCT LIMIT, 87.62,OTHER, 58.79, 133.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47210,AMB VARICELLA CHARGE -> VARICELLA VACCINE,90716,HCPCS,636,RC,8548365,CDM,,,,BOTH,1,EA, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47211,AMB PNEUMOCOCCAL 23-VALENT VACCINE CHARGE -> VACCINE PNEUMOCOCCAL 23-VALENT C,90732,HCPCS,636,RC,8526109,CDM,,,,BOTH,1,EA, 157.80, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 134.13,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47212,90732 PNEUMOVAX 23-PNEUMOCOCCAL POLY VAC 23-VALENT (PPSV23) ADULT OR IM,90732,HCPCS,636,RC,8044728,CDM,,,,BOTH,1,EA, 157.80, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 134.13,,OUTPCT LIMIT, 111.30,OTHER, 67.85, 154.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47213,AMB MENINGOCOCCAL CONJUGATE CHARGE -> VACCINE MENVEO,90734,HCPCS,636,RC,8965932,CDM,,,,BOTH,1,EA, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47214,AMB HEPATITIS B PEDIATRIC/ADOLESCENT CHARGE -> VACCINE HEPB (RECOMBIVAX),90744,HCPCS,636,RC,8555116,CDM,,,,BOTH,1,EA, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47215,90746 HEPATITIS B VACCINE (HEPB) ADULT DOSAGE 3 DOSE SCHEDULE FOR INTRAMUS,90746,HCPCS,636,RC,8044731,CDM,,,,BOTH,1,EA, 170.91, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 145.27,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47216,AMB HEPATITIS B VACCINE CHARGE -> 20MCG/ML HEPATITIS B VACCINE,90746,HCPCS,636,RC,8705857,CDM,,,,BOTH,20,ME, 170.91, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 145.27,,OUTPCT LIMIT, 104.75,OTHER, 73.49, 167.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47217,90756 INFLUENZA VIRUS VACCINE QUADRIVALENT (CCIIV4) 0.5 ML DOSAGE FOR IM USE,90756,HCPCS,636,RC,8113613,CDM,,,,BOTH,.5,ML, 10.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 8.50,,OUTPCT LIMIT, 12.78,OTHER, 4.30, 33.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47218,90785 INTERACTIVE COMPLEXITY,90785,HCPCS,919,RC,8040597,CDM,,,,OUTPATIENT,,, 33.06, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 28.10,,OUTPCT LIMIT, 17.36,OTHER, 5.09, 32.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47219,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,90791,HCPCS,919,RC,8040598,CDM,,,,OUTPATIENT,,, 303.91, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 258.32,,OUTPCT LIMIT, 184.48,OTHER, 130.68, 297.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47220,90792 PSYCHIATRIC DIAGNOSTIC EVALUATION,90792,HCPCS,919,RC,9026868,CDM,,,,OUTPATIENT,,, 340.51, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 289.43,,OUTPCT LIMIT, 202.35,OTHER, 146.42, 333.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47221,90832 PSYCHOTHERAPY 16-37 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90832,HCPCS,919,RC,8040600,CDM,,,,OUTPATIENT,,, 147.94, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 125.75,,OUTPCT LIMIT, 99.37,OTHER, 63.61, 144.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47222,90833 PSYCHOTHERAPY 30 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90833,HCPCS,919,RC,8040601,CDM,,,,OUTPATIENT,,, 152.07, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 129.26,,OUTPCT LIMIT, 88.44,OTHER, 59.56, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47223,90834 PSYCHOTHERAPY 38-52 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90834,HCPCS,919,RC,8040602,CDM,,,,OUTPATIENT,,, 195.87, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 166.49,,OUTPCT LIMIT, 131.72,OTHER, 84.22, 191.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47224,90836 PSYCHOTHERAPY 45 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90836,HCPCS,919,RC,8040603,CDM,,,,OUTPATIENT,,, 192.57, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 163.68,,OUTPCT LIMIT, 117.05,OTHER, 82.81, 188.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47225,90837 PSYCHOTHERAPY 53-67 MINUTES WITH PATIENT AND/OR FAMILY MEMBER,90837,HCPCS,919,RC,8040604,CDM,,,,OUTPATIENT,,, 294.22, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 250.09,,OUTPCT LIMIT, 179.75,OTHER, 126.51, 288.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47226,90838 PSYCHOTHERAPY 60 MINUTES W/ PATIENT AND/OR FAMILY MEMBER WHEN PERFORMED,90838,HCPCS,919,RC,8040605,CDM,,,,OUTPATIENT,,, 254.55, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 216.37,,OUTPCT LIMIT, 158.52,OTHER, 109.46, 249.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47227,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,90839,HCPCS,919,RC,8040606,CDM,,,,OUTPATIENT,,, 307.45, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 261.33,,OUTPCT LIMIT, 186.21,OTHER, 132.20, 301.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47228,90846 FAMILY PSYCHOTHERAPY W/O PATIENT 50 MINUTES,90840,HCPCS,919,RC,8621185,CDM,,,,OUTPATIENT,,, 147.11, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 125.04,,OUTPCT LIMIT, 83.96,OTHER, 50.93, 144.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47229,90840 PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MINUTES,90846,HCPCS,919,RC,8040607,CDM,,,,OUTPATIENT,,, 237.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 201.62,,OUTPCT LIMIT, 167.44,OTHER, 102.00, 232.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47230,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,90847,HCPCS,919,RC,8621186,CDM,,,,OUTPATIENT,,, 247.11, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 210.04,,OUTPCT LIMIT, 172.28,OTHER, 106.26, 242.17,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47231,90853 GROUP PSYCHOTHERAPY OTHER THAN FAMILY GROUP,90853,HCPCS,919,RC,8621189,CDM,,,,OUTPATIENT,,, 59.51, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 50.58,,OUTPCT LIMIT, 49.86,OTHER, 25.59, 87.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47232,SLP AUDITORY PROCESSING TX UNITS,92507,HCPCS,440,RC,1373841,CDM,,,GN,OUTPATIENT,,, 247.94, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 210.75,,OUTPCT LIMIT, 141.43,OTHER, 85.51, 242.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47233,92520 ST LARYNGEAL FUNCTION CHARGE,92520,HCPCS,440,RC,8385356,CDM,,,GN,OUTPATIENT,,, 105.62, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.78,,OUTPCT LIMIT, 69.71,OTHER, 45.42, 103.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47234,SLP EVALUATION OF SPEECH FLUENCY UNITS,92521,HCPCS,440,RC,7146947,CDM,,,GN,OUTPATIENT,,, 280.17, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 238.14,,OUTPCT LIMIT, 177.65,OTHER, 120.47, 274.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47235,SLP EVAL OF SPEECH SOUND PROD UNITS,92522,HCPCS,444,RC,2597752,CDM,,,GN,OUTPATIENT,,, 304.34, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 258.69,,OUTPCT LIMIT, 189.46,OTHER, 130.87, 298.25,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47236,SLP EVAL LANG COMPREHENSIONEXPRESS UNIT,92523,HCPCS,440,RC,2597754,CDM,,,GN,OUTPATIENT,,, 489.62, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 416.18,,OUTPCT LIMIT, 279.93,OTHER, 171.54, 479.83,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47237,BEHAVIORAL QUALITATIVE ANALYSIS UNITS,92524,HCPCS,440,RC,2597756,CDM,,,GN,OUTPATIENT,,, 459.04, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 390.18,,OUTPCT LIMIT, 265.00,OTHER, 171.54, 449.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47238,SLP SWALLOW DYSFUNCTION ORAL FEED UNITS,92526,HCPCS,440,RC,1373842,CDM,,,GN,OUTPATIENT,,, 251.59, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 213.85,,OUTPCT LIMIT, 149.90,OTHER, 108.18, 246.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47239,SLP SPEECH AAC EVAL FIRST HOUR UNITS,92607,HCPCS,440,RC,1373852,CDM,,,GN,OUTPATIENT,,, 319.55, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 271.62,,OUTPCT LIMIT, 167.02,OTHER, 46.09, 313.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47240,SLP SPEECH AAC EVAL ADDL HALF HOUR UNITS,92608,HCPCS,440,RC,1373854,CDM,,,GN,OUTPATIENT,,, 133.37, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 113.36,,OUTPCT LIMIT, 76.10,OTHER, 46.09, 130.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47241,SLP TX GENERATING DEVICE UNITS,92609,HCPCS,440,RC,1373849,CDM,,,GN,OUTPATIENT,,, 279.27, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 237.38,,OUTPCT LIMIT, 147.35,OTHER, 46.09, 273.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47242,SLP PHARYNGEAL SWALLOW EVAL UNITS,92610,HCPCS,440,RC,1373843,CDM,,,GN,OUTPATIENT,,, 404.70, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 344.00,,OUTPCT LIMIT, 227.22,OTHER, 124.32, 396.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47243,SLP FLUOROSCOPIC EVALUATION UNITS,92611,HCPCS,440,RC,1373839,CDM,,,GN,OUTPATIENT,,, 544.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 462.83,,OUTPCT LIMIT, 295.49,OTHER, 124.32, 533.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47244,SLP FIBEROPTIC SWALLOW EVAL UNITS,92612,HCPCS,440,RC,1373844,CDM,,,GN,OUTPATIENT,,, 173.65, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 147.60,,OUTPCT LIMIT, 114.40,OTHER, 74.67, 170.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47245,92616 ST FLEX ENDO EVAL W/LARYNGEAL SENSE TEST,92616,HCPCS,440,RC,8456647,CDM,,,GN,OUTPATIENT,,, 257.79, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 219.12,,OUTPCT LIMIT, 155.48,OTHER, 110.85, 252.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47246,93000 EKG W/AT LEAST 12 LEADS IANDR CHARGE,93000,HCPCS,730,RC,8326994,CDM,,,,OUTPATIENT,,, 39.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 33.96,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47247,93000 EKG W/ 12+ LEADS TRACING/INTERP/REPORT,93000,HCPCS,730,RC,8040276,CDM,,,,OUTPATIENT,,, 39.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 33.96,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47248,93000 EKG W/ 12+ LEADS,93000,HCPCS,730,RC,9578477,CDM,,,,OUTPATIENT,,, 39.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 33.96,,OUTPCT LIMIT, 25.61,OTHER, 17.18, 39.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47249,93005 EKG,93005,HCPCS,521,RC,8499789,CDM,,,,OUTPATIENT,,, 19.55, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 16.62,,OUTPCT LIMIT, 36.72,OTHER, 8.41, 114.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47250,EKG CHARGES - RT -> ROUTINE ECG 12 LEAD/15 LEAD TRACING ONLY,93005,HCPCS,730,RC,5367589,CDM,,,,OUTPATIENT,,, 368.35, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 313.10,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47251,EKG RT,93005,HCPCS,730,RC,8137327,CDM,,,,OUTPATIENT,,, 368.35, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 313.10,,OUTPCT LIMIT, 207.04,OTHER, 114.13, 360.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47252,CV STRESS TEST EO,93017,HCPCS,402,RC,8448654,CDM,,,TC,OUTPATIENT,,, 909.63, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 773.19,,OUTPCT LIMIT, 526.62,OTHER, 346.21, 891.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47253,CV STRESS TEST EO - REPORT,93017,HCPCS,999,RC,8448656,CDM,,,26,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 290.83,OTHER, 143.52, 346.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47254,93224 HOLTER ECG MONITOR UP TO 48 HR W/ SCAN INTERP AND REPORT,93224,HCPCS,976,RC,8040286,CDM,,,,OUTPATIENT,,, 333.27, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 283.28,,OUTPCT LIMIT, 266.67,OTHER, 147.17, 326.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47255,93242 EXT ECG RECORDING > 48HRS TO 7 DAYS BY CONT RHYTHM RECORDING CHARGE,93242,HCPCS,731,RC,8772595,CDM,,,,OUTPATIENT,,, 308.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 261.80,,OUTPCT LIMIT, 162.12,OTHER, 49.24, 301.84,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47256,HOLTER MONITOR 14 DAY,93246,HCPCS,460,RC,9332893,CDM,,,,OUTPATIENT,,, 248.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 210.80,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47257,93246 EXT ECG RECORDING FOR > 7 DAYS TO 15 DAYS BY CONT RHYTHM RECORDING,93246,HCPCS,731,RC,8772597,CDM,,,,OUTPATIENT,,, 248.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 210.80,,OUTPCT LIMIT, 140.39,OTHER, 80.99, 243.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47258,93270 REMOTE PT 30 DAY ECG CHARGE,93270,HCPCS,731,RC,8772598,CDM,,,,OUTPATIENT,,, 317.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 269.45,,OUTPCT LIMIT, 166.97,OTHER, 51.13, 310.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47259,93288 INTERROGATION DEVICE EVALUATION (IN PERSON) SINGLE DUAL OR MULTIPLE LEAD,93288,HCPCS,480,RC,8040305,CDM,,,,OUTPATIENT,,, 87.61, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 74.47,,OUTPCT LIMIT, 54.96,OTHER, 37.67, 85.86,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47260,93289 INTERROGATION DEVICE EVAL SINGLE DUAL OR MULTIPLE LEAD TRANSVENOUS IMPL,93289,HCPCS,521,RC,8040306,CDM,,,,OUTPATIENT,,, 152.07, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 129.26,,OUTPCT LIMIT, 86.43,OTHER, 51.13, 149.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47261,US ECHOCARDIOGRAM COMPLETE,93306,HCPCS,480,RC,8073910,CDM,,,TC,OUTPATIENT,,, 1626.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1382.68,,OUTPCT LIMIT, 950.56,OTHER, 656.16, 1594.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47262,US ECHOCARDIOGRAM COMPLETE - REPORT,93306,HCPCS,999,RC,8073912,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 375.80,OTHER, 121.44, 656.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47263,US ECHOCARDIOGRAM LIMITED,93308,HCPCS,480,RC,8073916,CDM,,,TC,OUTPATIENT,,, 930.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 790.50,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47264,US ECHO BUBBLE STUDY,93308,HCPCS,480,RC,8073898,CDM,,,TC,OUTPATIENT,,, 930.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 790.50,,OUTPCT LIMIT, 545.72,OTHER, 384.68, 911.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47265,US ECHO BUBBLE STUDY - REPORT,93308,HCPCS,999,RC,8073900,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47266,US ECHOCARDIOGRAM LIMITED - REPORT,93308,HCPCS,999,RC,8073918,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 278.85,OTHER, 121.44, 384.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47267,US CAROTID DUPLEX BILATERAL,93880,HCPCS,921,RC,1169631,CDM,,,TC,OUTPATIENT,,, 1102.27, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 936.93,,OUTPCT LIMIT, 591.97,OTHER, 225.62, 1080.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47268,REPORT US CAROTID DUPLEX BILATERAL,93880,HCPCS,999,RC,629663,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47269,US ABI COMPLETE BILATERAL,93922,HCPCS,921,RC,8073863,CDM,,,TC,OUTPATIENT,,, 465.69, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 395.84,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47270,US ABI,93922,HCPCS,921,RC,8044432,CDM,,,TC,OUTPATIENT,,, 465.69, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 395.84,,OUTPCT LIMIT, 250.40,OTHER, 96.59, 456.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47271,US ABI - REPORT,93923,HCPCS,999,RC,8044434,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 197.77,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47272,US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,402,RC,1169759,CDM,,,TC,OUTPATIENT,,, 1044.27, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 887.63,,OUTPCT LIMIT, 563.65,OTHER, 225.62, 1023.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47273,REPORT US LOWER EXT ARTERIAL DUPLEX BILATERAL,93925,HCPCS,999,RC,631052,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47274,US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,921,RC,1169761,CDM,,,TC|LT,OUTPATIENT,,, 163.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 138.55,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47275,US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,921,RC,1169763,CDM,,,TC|RT,OUTPATIENT,,, 163.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 138.55,,OUTPCT LIMIT, 113.30,OTHER, 70.09, 159.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47276,REPORT US LOWER EXT ARTERIAL DUPLEX RIGHT,93926,HCPCS,999,RC,631047,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47277,REPORT US LOWER EXT ARTERIAL DUPLEX LEFT,93926,HCPCS,999,RC,631050,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47278,US UPPER EXT ARTERIAL DUPLEX BILATERAL,93930,HCPCS,921,RC,1169895,CDM,,,TC|50,OUTPATIENT,,, 500.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 425.00,,OUTPCT LIMIT, 297.88,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47279,US UPPER EXT ARTERIAL DUPLEX BILATERAL - REPORT,93930,HCPCS,999,RC,630818,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47280,US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,921,RC,1169897,CDM,,,TC|LT,OUTPATIENT,,, 467.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 397.59,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47281,US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,921,RC,1169899,CDM,,,TC|RT,OUTPATIENT,,, 467.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 397.59,,OUTPCT LIMIT, 262.11,OTHER, 141.55, 458.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47282,REPORT US UPPER EXT ARTERIAL DUPLEX LEFT,93931,HCPCS,999,RC,630814,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47283,REPORT US UPPER EXT ARTERIAL DUPLEX RIGHT,93931,HCPCS,999,RC,630810,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47284,US LOWER EXT VENOUS REFLUX BILATERAL,93970,HCPCS,402,RC,8073922,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1079.04,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47285,US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169901,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1079.04,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47286,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI,93970,HCPCS,921,RC,8291851,CDM,,,TC|50,OUTPATIENT,,, 674.48, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 573.31,,OUTPCT LIMIT, 383.08,OTHER, 225.62, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47287,US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,921,RC,1169769,CDM,,,TC,OUTPATIENT,,, 1269.46, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1079.04,,OUTPCT LIMIT, 673.61,OTHER, 225.62, 1244.07,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47288,REPORT US LOWER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,631030,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47289,US LOWER EXT VENOUS REFLUX BILATERAL - REPORT,93970,HCPCS,999,RC,8073924,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47290,US LOWER EXT ARTERIAL DUPLEX BILAT W/ABI - REPORT,93970,HCPCS,999,RC,8291853,CDM,,,26|50,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47291,REPORT US UPPER EXT VENOUS DUPLEX BILATERAL,93970,HCPCS,999,RC,630808,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47292,US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,402,RC,1169771,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 573.31,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47293,US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,921,RC,1169903,CDM,,,TC|LT,OUTPATIENT,,, 674.48, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 573.31,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47294,US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169773,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 573.31,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47295,US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,921,RC,1169905,CDM,,,TC|RT,OUTPATIENT,,, 674.48, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 573.31,,OUTPCT LIMIT, 363.06,OTHER, 141.55, 660.99,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47296,REPORT US LOWER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,631025,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47297,REPORT US UPPER EXT VENOUS DUPLEX LEFT,93971,HCPCS,999,RC,630806,CDM,,,26|LT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47298,REPORT US UPPER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,630802,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47299,REPORT US LOWER EXT VENOUS DUPLEX RIGHT,93971,HCPCS,999,RC,631020,CDM,,,26|RT,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 192.01,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47300,US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,921,RC,1169577,CDM,,,TC,OUTPATIENT,,, 1232.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1047.31,,OUTPCT LIMIT, 655.39,OTHER, 225.62, 1207.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47301,REPORT US AORTA IVC ILIAC DUPLEX COMPLETE,93978,HCPCS,999,RC,625733,CDM,,,26,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 222.04,OTHER, 121.44, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47302,RT VENTILATOR CHECK CHARGE,94002,HCPCS,410,RC,8099218,CDM,,,,OUTPATIENT,,, 2591.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2202.35,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47303,RT VENTILATOR SERVICES INITIAL CHARGE,94002,HCPCS,410,RC,8099161,CDM,,,,OUTPATIENT,,, 1399.48, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1189.56,,OUTPCT LIMIT, 1042.14,OTHER, 284.89, 2539.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47304,RT CHARGE PFT -> SPIROMETRY,94010,HCPCS,460,RC,5274349,CDM,,,,OUTPATIENT,,, 436.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 370.60,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47305,RT INCENTIVE SPIROMETRY INITIAL CHARGE,94010,HCPCS,460,RC,8099140,CDM,,,,OUTPATIENT,,, 92.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 78.20,,OUTPCT LIMIT, 184.77,OTHER, 39.56, 427.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47306,RT CHARGE PFT -> SPIROMETRY BEFORE AND AFTER,94060,HCPCS,460,RC,5267139,CDM,,,,OUTPATIENT,,, 1053.38, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 895.37,,OUTPCT LIMIT, 547.41,OTHER, 138.71, 1032.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47307,SIX MINUTE WALK,94618,HCPCS,460,RC,4629931,CDM,,,,OUTPATIENT,,, 241.59, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 205.35,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47308,SIX MINUTE WALK,94618,HCPCS,460,RC,4630253,CDM,,,,OUTPATIENT,,, 241.59, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 205.35,,OUTPCT LIMIT, 154.36,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47309,RT AEROSOL SUBSEQUENT CHARGE,94640,HCPCS,412,RC,8099123,CDM,,,,OUTPATIENT,,, 292.53, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 248.65,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47310,RT AEROSOL INITIAL CHARGE,94640,HCPCS,412,RC,8099122,CDM,,,,OUTPATIENT,,, 292.53, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 248.65,,OUTPCT LIMIT, 199.86,OTHER, 125.79, 286.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47311,RT BIPAP SUBSEQUENT CHARGE,94660,HCPCS,410,RC,8099125,CDM,,,,OUTPATIENT,,, 612.37, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 520.51,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47312,RT CPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099126,CDM,,,,OUTPATIENT,,, 803.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 682.55,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47313,RT BIPAP INITIAL CHARGE,94660,HCPCS,410,RC,8099124,CDM,,,,OUTPATIENT,,, 882.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 749.70,,OUTPCT LIMIT, 407.38,OTHER, 140.42, 864.36,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47314,RT CPAP SUBSEQUENT CHARGE,94660,HCPCS,460,RC,8099127,CDM,,,,OUTPATIENT,,, 612.37, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 520.51,,OUTPCT LIMIT, 332.46,OTHER, 140.42, 600.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47315,RT METER DOSE INHALER INITIAL CHARGE,94664,HCPCS,410,RC,8099146,CDM,,,,OUTPATIENT,,, 372.76, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 316.85,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47316,RT METER DOSE INHALER SUBSEQUENT CHARGE,94664,HCPCS,410,RC,8099147,CDM,,,,OUTPATIENT,,, 372.76, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 316.85,,OUTPCT LIMIT, 239.03,OTHER, 160.29, 365.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47317,RT CPT INITIAL CHARGE,94667,HCPCS,410,RC,8099130,CDM,,,,OUTPATIENT,,, 241.59, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 205.35,,OUTPCT LIMIT, 174.98,OTHER, 103.88, 239.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47318,RT CPT SUBSEQUENT CHARGE,94668,HCPCS,410,RC,8099131,CDM,,,,OUTPATIENT,,, 241.59, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 205.35,,OUTPCT LIMIT, 136.10,OTHER, 76.16, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47319,RT CHARGE PFT -> BODY PLETHYSMOGRAPHY (THROACIC GAS VOLUME),94726,HCPCS,460,RC,9481292,CDM,,,,OUTPATIENT,,, 173.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 147.05,,OUTPCT LIMIT, 140.33,OTHER, 74.39, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47320,RT CHARGE PFT -> DIFFUSION (DLCO),94729,HCPCS,460,RC,5267130,CDM,,,,OUTPATIENT,,, 425.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 361.25,,OUTPCT LIMIT, 228.33,OTHER, 87.35, 416.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47321,RT POX SINGLE DETERMINATION CHARGE,94760,HCPCS,460,RC,8099206,CDM,,,,OUTPATIENT,,, 53.34, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 45.34,,OUTPCT LIMIT, 34.19,OTHER, 22.94, 52.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47322,RT POX MULTIPLE DETERMINATION CHARGE,94761,HCPCS,460,RC,8099205,CDM,,,,OUTPATIENT,,, 104.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 88.40,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47323,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099197,CDM,,,,OUTPATIENT,,, 327.65, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 278.50,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47324,RT OVERNIGHT OXIMETRY CHARGE,94762,HCPCS,460,RC,8099038,CDM,,,,OUTPATIENT,,, 327.65, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 278.50,,OUTPCT LIMIT, 182.46,OTHER, 94.34, 321.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47325,PEAK FLOW,94799,HCPCS,460,RC,785847,CDM,,,,OUTPATIENT,,, 143.43, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 121.92,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47326,PEAK FLOW METER USE,94799,HCPCS,460,RC,783859,CDM,,,,OUTPATIENT,,, 143.43, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 121.92,,OUTPCT LIMIT, 125.89,OTHER, 61.67, 234.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47327,HOME SLEEP STUDY,95806,HCPCS,920,RC,8345548,CDM,,,,OUTPATIENT,,, 736.19, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 625.76,,OUTPCT LIMIT, 415.63,OTHER, 235.80, 721.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47328,95810 PRO POLYSOMNOGRAPHY CHARGE,95810,HCPCS,920,RC,9381517,CDM,,,,OUTPATIENT,,, 3250.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2762.50,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47329,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95810,HCPCS,920,RC,2388940,CDM,,,,OUTPATIENT,,, 3250.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2762.50,,OUTPCT LIMIT, 1853.96,OTHER, 1121.15, 3185.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47330,95811 POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,8218527,CDM,,,,OUTPATIENT,,, 3900.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3315.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47331,95811 PRO POLYSOMNOGRAPHY W/CPAP CHARGE,95811,HCPCS,920,RC,9385667,CDM,,,,OUTPATIENT,,, 3900.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3315.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47332,POLYSOMNOGRAPHY AGE 6 YEARS OR OLDER SLEEP STAGING WITH 4 OR MORE ADDITIONAL,95811,HCPCS,920,RC,2388941,CDM,,,,OUTPATIENT,,, 3900.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3315.00,,OUTPCT LIMIT, 2171.37,OTHER, 1121.15, 3822.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47333,SLP ASSESSMENT OF APHASIA UNITS,96105,HCPCS,440,RC,1373853,CDM,,,GN,OUTPATIENT,,, 271.22, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 230.54,,OUTPCT LIMIT, 152.82,OTHER, 85.61, 265.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47334,SLP COGNITIVE TEST UNITS,96125,HCPCS,440,RC,9013348,CDM,,,GN,OUTPATIENT,,, 296.28, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 251.84,,OUTPCT LIMIT, 165.98,OTHER, 89.47, 290.35,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47335,96360 IV HYDRATION INIT UP TO 1HR,96360,HCPCS,260,RC,8022353,CDM,,,,OUTPATIENT,,, 480.27, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 408.23,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47336,96360 - HYDRATION FIRST HOUR,96360,HCPCS,260,RC,1928297,CDM,,,,OUTPATIENT,,, 480.27, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 408.23,,OUTPCT LIMIT, 260.74,OTHER, 110.12, 470.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47337,96361- HYDRATION EACH ADDITIONAL HOUR,96361,HCPCS,260,RC,1928298,CDM,,,,OUTPATIENT,,, 180.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 153.17,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47338,96361 IV HYDRATION EA ADD HR,96361,HCPCS,260,RC,8022354,CDM,,,,OUTPATIENT,,, 180.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 153.17,,OUTPCT LIMIT, 96.89,OTHER, 37.34, 176.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47339,96365 IV INF INIT ^2-1HR,96365,HCPCS,260,RC,8022356,CDM,,,,OUTPATIENT,,, 571.66, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 485.91,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47340,96365 IV INFUSION 1ST HOUR CHARGE,96365,HCPCS,260,RC,8612057,CDM,,,,OUTPATIENT,,, 571.66, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 485.91,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47341,96365- IV TX FIRST HOUR,96365,HCPCS,260,RC,1928299,CDM,,,,OUTPATIENT,,, 571.66, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 485.91,,OUTPCT LIMIT, 323.07,OTHER, 184.46, 560.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47342,96366- IV TX EACH ADDITIONAL HOUR,96366,HCPCS,260,RC,1928300,CDM,,,,OUTPATIENT,,, 164.70, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 140.00,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47343,96366 IV INFUSION EA ADDT'L HR,96366,HCPCS,260,RC,8022357,CDM,,,,OUTPATIENT,,, 164.77, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 140.05,,OUTPCT LIMIT, 89.33,OTHER, 37.34, 161.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47344,96367 IV INFUS ADD SEQ NEW 1HR,96367,HCPCS,260,RC,8022358,CDM,,,,OUTPATIENT,,, 196.43, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 166.97,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47345,96367- IV TX SEQUENTIAL INFUSION,96367,HCPCS,260,RC,8197814,CDM,,,,OUTPATIENT,,, 196.43, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 166.97,,OUTPCT LIMIT, 108.89,OTHER, 54.48, 192.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47346,96368 INFUSION THERAPY CONCURRENT,96368,HCPCS,260,RC,8022359,CDM,,,,OUTPATIENT,,, 143.94, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 122.35,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47347,96368- IV TX CONCURRENT INFUSION,96368,HCPCS,260,RC,1928302,CDM,,,,OUTPATIENT,,, 143.94, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 122.35,,OUTPCT LIMIT, 92.25,OTHER, 61.89, 141.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47348,96372- SUBQ/IM INJECTION,96372,HCPCS,260,RC,1928303,CDM,,,,OUTPATIENT,,, 153.89, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 130.81,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47349,96372 INJ IM/SUB THERAPUTIC/DIAGNOS,96372,HCPCS,260,RC,8022360,CDM,,,,OUTPATIENT,,, 153.89, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 130.81,,OUTPCT LIMIT, 84.04,OTHER, 37.34, 150.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47350,96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM PROFEE,96372,HCPCS,521,RC,8534483,CDM,,,,OUTPATIENT,,, 59.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 50.58,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47351,96372 THERAPEUTIC PROPHYLACTIC OR DIAGNOSTIC INJECTION,96372,HCPCS,521,RC,8044862,CDM,,,,OUTPATIENT,,, 59.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 50.58,,OUTPCT LIMIT, 37.95,OTHER, 25.59, 58.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47352,96374- IV INJECTION SINGLE/INITIAL,96374,HCPCS,260,RC,1928305,CDM,,,,OUTPATIENT,,, 300.84, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 255.71,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47353,96374 IV PUSH SING/INITIAL,96374,HCPCS,260,RC,8022361,CDM,,,,OUTPATIENT,,, 300.84, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 255.71,,OUTPCT LIMIT, 159.88,OTHER, 54.48, 294.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47354,96375 IVP ADDITIONAL INFUSION,96375,HCPCS,260,RC,8022362,CDM,,,,OUTPATIENT,,, 170.93, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 145.29,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47355,96375- IV INJECTION ADD NEW DRUG,96375,HCPCS,260,RC,1928306,CDM,,,,OUTPATIENT,,, 170.93, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 145.29,,OUTPCT LIMIT, 96.44,OTHER, 54.48, 167.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47356,96376 ADL SEQ IV PUSH SAME MED,96376,HCPCS,260,RC,8022363,CDM,,,,OUTPATIENT,,, 172.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 146.63,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47357,96376- IV INJECTION ADD SAME DRUG,96376,HCPCS,260,RC,1928307,CDM,,,,OUTPATIENT,,, 172.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 146.63,,OUTPCT LIMIT, 110.56,OTHER, 74.18, 169.05,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47358,PT MECHANICAL TRACTION ASSISTANT UNITS,97012,HCPCS,420,RC,8139641,CDM,,,GP,OUTPATIENT,,, 87.96, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 74.77,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47359,PT MECHANICAL TRACTION UNITS,97012,HCPCS,420,RC,1373912,CDM,,,GP,OUTPATIENT,,, 87.96, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 74.77,,OUTPCT LIMIT, 47.95,OTHER, 21.01, 86.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47360,PT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,420,RC,7139403,CDM,,,GP,OUTPATIENT,,, 96.54, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 82.06,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47361,OT WHIRLPOOL FLUIDOTHERAPY UNITS,97022,HCPCS,430,RC,1373554,CDM,,,GO,OUTPATIENT,,, 96.54, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 82.06,,OUTPCT LIMIT, 55.33,OTHER, 34.39, 94.61,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47362,PT ATTENDED E-STIM UNITS,97032,HCPCS,420,RC,7139395,CDM,,,GP,OUTPATIENT,,, 105.79, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.92,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47363,PT ATTENDED E-STIM ASSISTANT UNITS,97032,HCPCS,420,RC,8139671,CDM,,,GP,OUTPATIENT,,, 105.79, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.92,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47364,OT ATTENDED E-STIM UNITS,97032,HCPCS,430,RC,1373442,CDM,,,GO,OUTPATIENT,,, 105.79, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.92,,OUTPCT LIMIT, 58.74,OTHER, 29.74, 103.67,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47365,PT ULTRASOUND ASSISTANT UNITS,97035,HCPCS,420,RC,8139677,CDM,,,GP,OUTPATIENT,,, 420.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 357.00,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47366,PT ULTRASOUND UNITS,97035,HCPCS,420,RC,1374021,CDM,,,GP,OUTPATIENT,,, 134.85, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 114.62,,OUTPCT LIMIT, 142.33,OTHER, 28.82, 411.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47367,OT ULTRASOUND UNITS,97035,HCPCS,430,RC,1373448,CDM,,,GO,OUTPATIENT,,, 134.85, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 114.62,,OUTPCT LIMIT, 72.71,OTHER, 28.82, 132.15,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47368,PT THERAPEUTIC EXERCISE ASSISTANT UNITS,97110,HCPCS,420,RC,8139679,CDM,,,GP,OUTPATIENT,,, 122.88, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 104.45,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47369,PT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,420,RC,1374020,CDM,,,GP,OUTPATIENT,,, 122.80, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 104.38,,OUTPCT LIMIT, 74.33,OTHER, 52.80, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47370,OT THERAPEUTIC EXERCISE UNITS,97110,HCPCS,430,RC,1373449,CDM,,,GO,OUTPATIENT,,, 122.88, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 104.45,,OUTPCT LIMIT, 74.35,OTHER, 52.84, 120.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47371,PT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,420,RC,1373913,CDM,,,GP,OUTPATIENT,,, 131.06, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 111.40,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47372,PT NEUROMUSCULAR REEDUCATION ASSISTANT UNITS,97112,HCPCS,420,RC,8139693,CDM,,,GP,OUTPATIENT,,, 131.06, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 111.40,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47373,OT NEUROMUSCULAR REEDUCATION UNITS,97112,HCPCS,430,RC,1373446,CDM,,,GO,OUTPATIENT,,, 131.06, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 111.40,,OUTPCT LIMIT, 80.43,OTHER, 56.36, 128.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47374,PT GAIT TRAINING ASSISTANT UNITS,97116,HCPCS,420,RC,8139685,CDM,,,GP,OUTPATIENT,,, 95.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 80.86,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47375,PT GAIT TRAINING UNITS,97116,HCPCS,420,RC,1374013,CDM,,,GP,OUTPATIENT,,, 95.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 80.86,,OUTPCT LIMIT, 60.80,OTHER, 40.91, 93.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47376,OT MASSAGE UNITS,97124,HCPCS,430,RC,1373445,CDM,,,GO,OUTPATIENT,,, 67.62, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 57.48,,OUTPCT LIMIT, 47.68,OTHER, 29.08, 66.27,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47377,OT COG THER INTERVENTFIRST 15 MIN UNITS,97129,HCPCS,430,RC,8139487,CDM,,,GO,OUTPATIENT,,, 179.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 152.15,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47378,97129 OT COGNITIVE THERAPY INTERVENTION FIRST 15 MINS,97129,HCPCS,430,RC,8230798,CDM,,,GO,OUTPATIENT,,, 179.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 152.15,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47379,SLP COG THER INTERVENTFIRST 15MIN UNITS,97129,HCPCS,440,RC,8139531,CDM,,,GN,OUTPATIENT,,, 179.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 152.15,,OUTPCT LIMIT, 98.59,OTHER, 46.96, 175.42,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47380,97130 OT COGNITIVE THERAPY INTERVENTION ADDTIONAL 15 MINS,97130,HCPCS,430,RC,8230800,CDM,,,GO,OUTPATIENT,,, 215.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 182.75,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47381,OT COG THER INTERVENT ADDL 15 MIN UNITS,97130,HCPCS,430,RC,8139493,CDM,,,GO,OUTPATIENT,,, 215.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 182.75,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47382,SLP COG THER INTERVENT ADDL 15MIN UNITS,97130,HCPCS,440,RC,8139535,CDM,,,GN,OUTPATIENT,,, 215.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 182.75,,OUTPCT LIMIT, 115.67,OTHER, 44.87, 210.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47383,PT MANUAL THERAPY ASSISTANT UNITS,97140,HCPCS,420,RC,8139689,CDM,,,GP,OUTPATIENT,,, 122.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 104.27,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47384,PT MANUAL THERAPY UNITS,97140,HCPCS,420,RC,1373910,CDM,,,GP,OUTPATIENT,,, 122.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 104.27,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47385,OT MANUAL THERAPY UNITS,97140,HCPCS,430,RC,1373444,CDM,,,GO,OUTPATIENT,,, 122.67, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 104.27,,OUTPCT LIMIT, 73.14,OTHER, 52.75, 120.22,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47386,OT GROUP THERAPY UNITS,97150,HCPCS,430,RC,1373451,CDM,,,GO,OUTPATIENT,,, 44.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 37.40,,OUTPCT LIMIT, 30.33,OTHER, 18.92, 43.12,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47387,PT EVALUATION UNITS LOW COMPLEXITY,97161,HCPCS,424,RC,7930588,CDM,,,GP,OUTPATIENT,,, 265.04, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 225.28,,OUTPCT LIMIT, 178.52,OTHER, 113.97, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47388,PT EVALUATION UNITS MODERATE COMPLEXITY,97162,HCPCS,424,RC,7930592,CDM,,,GP,OUTPATIENT,,, 314.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 267.33,,OUTPCT LIMIT, 202.67,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47389,PT EVALUATION UNITS HIGH COMPLEXITY,97163,HCPCS,424,RC,7930596,CDM,,,GP,OUTPATIENT,,, 297.77, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 253.10,,OUTPCT LIMIT, 194.50,OTHER, 128.04, 291.81,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47390,PT RE-EVALUATION UNITS 97164,97164,HCPCS,424,RC,7930600,CDM,,,GP,OUTPATIENT,,, 148.36, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 126.11,,OUTPCT LIMIT, 106.37,OTHER, 63.79, 145.39,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47391,OT EVALUATION UNITS LOW COMPLEXITY,97165,HCPCS,434,RC,7930556,CDM,,,GO,OUTPATIENT,,, 254.33, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 216.18,,OUTPCT LIMIT, 173.75,OTHER, 109.36, 249.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47392,OT EVALUATION UNITS MODERATE COMPLEXITY,97166,HCPCS,434,RC,7930560,CDM,,,GO,OUTPATIENT,,, 268.84, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 228.51,,OUTPCT LIMIT, 180.83,OTHER, 115.60, 263.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47393,OT EVALUATION UNITS HIGH COMPLEXITY,97167,HCPCS,434,RC,7930564,CDM,,,GO,OUTPATIENT,,, 317.29, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 269.70,,OUTPCT LIMIT, 204.49,OTHER, 136.43, 310.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47394,OT RE-EVALUATION UNITS 97168,97168,HCPCS,434,RC,7930568,CDM,,,GO,OUTPATIENT,,, 153.24, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 130.25,,OUTPCT LIMIT, 108.91,OTHER, 65.89, 150.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47395,PT THERAPEUTIC ACTIVITY UNITS,97530,HCPCS,420,RC,1374031,CDM,,,GP,OUTPATIENT,,, 120.71, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 102.60,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47396,PT THERAPEUTIC ACTIVITY ASSISTANT UNITS,97530,HCPCS,420,RC,8139691,CDM,,,GP,OUTPATIENT,,, 120.71, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 102.60,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47397,OT THERAPEUTIC ACTIVITIES UNITS,97530,HCPCS,430,RC,1373450,CDM,,,GO,OUTPATIENT,,, 120.71, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 102.60,,OUTPCT LIMIT, 68.75,OTHER, 41.16, 118.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47398,OT SENSORY INTEGRATIVE TECHNIQUES UNITS,97533,HCPCS,430,RC,1373568,CDM,,,GO,OUTPATIENT,,, 73.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 62.39,,OUTPCT LIMIT, 44.69,OTHER, 31.56, 71.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47399,PT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,420,RC,1374117,CDM,,,GP,OUTPATIENT,,, 127.65, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 108.50,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47400,PT SELF CARE HOME MANAGEMENT ASSISTANT UNITS,97535,HCPCS,420,RC,8139697,CDM,,,GP,OUTPATIENT,,, 127.65, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 108.50,,OUTPCT LIMIT, 78.22,OTHER, 54.89, 125.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47401,OT SELF CARE HOME MANAGEMENT UNITS,97535,HCPCS,430,RC,1373569,CDM,,,GO,OUTPATIENT,,, 88.62, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 75.33,,OUTPCT LIMIT, 59.17,OTHER, 38.11, 86.85,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47402,PT WHIRLPOOL THERAPY ASSISTANT UNITS,97542,HCPCS,420,RC,8139501,CDM,,,GP,OUTPATIENT,,, 116.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 98.60,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47403,PT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,420,RC,1373917,CDM,,,GP,OUTPATIENT,,, 116.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 98.60,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47404,OT WHEELCHAIR MANAGEMENT UNITS,97542,HCPCS,430,RC,1373570,CDM,,,GO,OUTPATIENT,,, 116.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 98.60,,OUTPCT LIMIT, 66.10,OTHER, 39.73, 113.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47405,97598 DEBRID SELCT EA ADD20SQCM PROFEE,97598,HCPCS,999,RC,8022377,CDM,,,,OUTPATIENT,,, 29.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 24.65,,OUTPCT LIMIT, 68.90,OTHER, 12.81, 151.16,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47406,OT ORTHOTIC MANAGEMENT TRAIN UNITS,97760,HCPCS,430,RC,1373573,CDM,,,GO,OUTPATIENT,,, 143.76, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 122.20,,OUTPCT LIMIT, 93.12,OTHER, 61.82, 140.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47407,PT PROSTHETIC MANAGEMENT TRAIN UNITS,97761,HCPCS,420,RC,1374121,CDM,,,GP,OUTPATIENT,,, 121.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 102.85,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47408,PT PROSTHETIC MANAGEMENT TRAIN ASSISTANT UNITS,97761,HCPCS,420,RC,8139709,CDM,,,GP,OUTPATIENT,,, 265.04, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 225.28,,OUTPCT LIMIT, 114.40,OTHER, 52.03, 259.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47409,OT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402197,CDM,,,GO,OUTPATIENT,,, 124.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 105.40,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47410,PT ORTHOTIC/PROSTHETIC MANAGETRAIN UNITS,97763,HCPCS,430,RC,9402217,CDM,,,GO,OUTPATIENT,,, 124.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 105.40,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47411,OT ORTHOTIC/PROSTHETIC MANAGEMENT/TRAINING UNIT,97763,HCPCS,430,RC,9407395,CDM,,,GO,OUTPATIENT,,, 124.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 105.40,,OUTPCT LIMIT, 85.61,OTHER, 53.32, 121.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47412,TELEPHONE EST 5 TO 10 MINUTES 98004,98004,HCPCS,521,RC,1027772,CDM,,,,OUTPATIENT,,, 75.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 63.75,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47413,TELEPHONE EST 11 TO 20 MINUTES 98005,98005,HCPCS,521,RC,1027773,CDM,,,,OUTPATIENT,,, 104.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 88.40,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47414,TELEPHONE EST 21 TO 30 MINUTES 98006,98006,HCPCS,521,RC,1027774,CDM,,,,OUTPATIENT,,, 141.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 119.85,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47415,99442 TELEPHONE VISIT - ESTABLISHED PATIENT 11-20 MIN,98013,HCPCS,521,RC,8040761,CDM,,,,OUTPATIENT,,, 104.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 88.40,,OUTPCT LIMIT, 66.66,OTHER, 44.72, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47416,99443 TELEPHONE EVAL 21-30 MINUTES,98014,HCPCS,521,RC,8194815,CDM,,,,OUTPATIENT,,, 141.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 119.85,,OUTPCT LIMIT, 90.37,OTHER, 60.63, 138.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47417,98016 TELEHEALTH VIRTUAL CHECK IN -BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE,98016,HCPCS,521,RC,8194477,CDM,,,,OUTPATIENT,,, 75.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 63.75,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47418,99441 TELEPHONE EVAL 5-10 MINUTES,98016,HCPCS,521,RC,8194813,CDM,,,,OUTPATIENT,,, 75.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 63.75,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47419,BILL ONLY SPEC TRAN CHCO,99002,HCPCS,300,RC,9576527,CDM,,,,OUTPATIENT,,, 300.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 255.00,,OUTPCT LIMIT, 192.27,OTHER, 129.00, 294.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47420,99100 ANES EXTREME AGE <1AND>70YR PROFEE,99100,HCPCS,999,RC,8022390,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47421,99140 EMERGENCY CONDITIONS PROFEE,99140,HCPCS,999,RC,8022391,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 84.02,OTHER, 46.37, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47422,THER PHLEB,99195,HCPCS,300,RC,8045344,CDM,,,,OUTPATIENT,,, 241.59, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 205.35,,OUTPCT LIMIT, 145.27,OTHER, 103.88, 236.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47423,99202 OFFICE VISIT NEW PT. LEVEL 2 15-29 MIN,99202,HCPCS,521,RC,8938244,CDM,,,,OUTPATIENT,,, 148.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 126.44,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47424,99202 OFFICE VISIT NEW PT. LEVEL 2,99202,HCPCS,521,RC,8284445,CDM,,,,OUTPATIENT,,, 148.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 126.44,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47425,99203 OFFICE VISIT NEW PT. LEVEL 3 30-44 MIN,99203,HCPCS,521,RC,8938245,CDM,,,,OUTPATIENT,,, 252.07, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 214.26,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47426,99203 OFFICE VISIT NEW PT. LEVEL 3,99203,HCPCS,521,RC,8284446,CDM,,,,OUTPATIENT,,, 252.07, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 214.26,,OUTPCT LIMIT, 161.56,OTHER, 108.39, 247.03,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47427,99204 OFFICE VISIT NEW PT. LEVEL 4 45-59 MIN,99204,HCPCS,521,RC,8948854,CDM,,,,OUTPATIENT,,, 394.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 335.24,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47428,99204 OFFICE VISIT NEW PT. LEVEL 4,99204,HCPCS,521,RC,8284447,CDM,,,,OUTPATIENT,,, 394.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 335.24,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47429,99205 OFFICE VISIT NEW PT. LEVEL 5,99205,HCPCS,521,RC,8284448,CDM,,,,OUTPATIENT,,, 491.30, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 417.61,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47430,99205 OFFICE VISIT NEW PT. LEVEL 5 60-74 MIN,99205,HCPCS,521,RC,8948855,CDM,,,,OUTPATIENT,,, 491.30, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 417.61,,OUTPCT LIMIT, 314.88,OTHER, 211.26, 481.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47431,99211 OFFICE VISIT ESTABLISHED PT. LEVEL 1,99211,HCPCS,521,RC,8284449,CDM,,,,OUTPATIENT,,, 47.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 40.46,,OUTPCT LIMIT, 30.51,OTHER, 20.47, 46.65,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47432,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2,99212,HCPCS,521,RC,8284450,CDM,,,,OUTPATIENT,,, 103.70, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 88.15,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47433,99212 OFFICE VISIT ESTABLISHED PT. LEVEL 2 10-19 MIN,99212,HCPCS,521,RC,8948856,CDM,,,,OUTPATIENT,,, 103.70, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 88.15,,OUTPCT LIMIT, 66.46,OTHER, 44.59, 101.63,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47434,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,99213,HCPCS,521,RC,8284451,CDM,,,,OUTPATIENT,,, 173.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 147.39,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47435,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3 20-29 MIN,99213,HCPCS,521,RC,8938246,CDM,,,,OUTPATIENT,,, 173.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 147.39,,OUTPCT LIMIT, 111.13,OTHER, 74.56, 169.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47436,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4,99214,HCPCS,521,RC,8284452,CDM,,,,OUTPATIENT,,, 255.85, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 217.47,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47437,99214 OFFICE VISIT ESTABLISHED PT. LEVEL 4 30-39 MIN,99214,HCPCS,521,RC,8938247,CDM,,,,OUTPATIENT,,, 255.85, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 217.47,,OUTPCT LIMIT, 163.98,OTHER, 110.02, 250.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47438,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5,99215,HCPCS,521,RC,8284453,CDM,,,,OUTPATIENT,,, 342.55, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 291.17,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47439,99215 OFFICE VISIT ESTABLISHED PT. LEVEL 5 40-54 MIN,99215,HCPCS,521,RC,8938248,CDM,,,,OUTPATIENT,,, 342.55, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 291.17,,OUTPCT LIMIT, 219.55,OTHER, 147.30, 335.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47440,99222 INITIAL HOSP INPT OR OBS CARE MODERATE 55 MIN PROFEE,99222,HCPCS,999,RC,8893313,CDM,,,,OUTPATIENT,,, 340.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 289.00,,OUTPCT LIMIT, 272.06,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47441,99223 INITIAL HOSP INPT OR OBS CARE HIGH 75 MIN PROFEE,99223,HCPCS,999,RC,8891444,CDM,,,,OUTPATIENT,,, 421.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 357.85,,OUTPCT LIMIT, 336.87,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47442,99231 LEVEL 1 VISIT STABLE IMPROVING 25 MIN PROFEE,99231,HCPCS,999,RC,8022427,CDM,,,,OUTPATIENT,,, 145.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 123.25,,OUTPCT LIMIT, 111.61,OTHER, 64.03, 142.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47443,99232 LEVEL 2 VISIT MINOR COMPLICATION 35 MIN PROFEE,99232,HCPCS,999,RC,8022428,CDM,,,,OUTPATIENT,,, 177.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 150.45,,OUTPCT LIMIT, 149.82,OTHER, 78.16, 173.46,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47444,99233 LEVEL 3 VISIT UNSTABLE MAJOR COMPLICATION 50 MIN PROFEE,99233,HCPCS,999,RC,8022429,CDM,,,,OUTPATIENT,,, 256.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 217.60,,OUTPCT LIMIT, 220.11,OTHER, 113.05, 250.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47445,99281 EMERGENCY DEPARTMENT VISIT LEVEL 1,99281,HCPCS,450,RC,8040686,CDM,,,25,OUTPATIENT,,, 268.92, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 228.58,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47446,99281 - LEVEL 1,99281,HCPCS,450,RC,2644297,CDM,,,25,OUTPATIENT,,, 268.92, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 228.58,,OUTPCT LIMIT, 149.74,OTHER, 77.35, 263.54,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47447,99281 EMERGENCY DEPT VISIT LEVEL 1 PROFEE,99281,HCPCS,960,RC,8042517,CDM,,,,OUTPATIENT,,, 251.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 213.35,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47448,99281 BRIEF SERVICE PROFEE,99281,HCPCS,999,RC,8022448,CDM,,,,OUTPATIENT,,, 251.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 213.35,,OUTPCT LIMIT, 156.74,OTHER, 77.35, 245.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47449,99282 EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY TECH FEE,99282,HCPCS,450,RC,8345559,CDM,,,25,OUTPATIENT,,, 416.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 353.60,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47450,99282 - LEVEL 2,99282,HCPCS,450,RC,2644298,CDM,,,25,OUTPATIENT,,, 416.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 353.60,,OUTPCT LIMIT, 233.57,OTHER, 127.82, 407.68,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47451,99282 EMERGENCY DEPT VISIT LEVEL 2 PROFEE,99282,HCPCS,960,RC,8042518,CDM,,,,OUTPATIENT,,, 296.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 251.60,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47452,99282 LIMITED SERVICE PROFEE,99282,HCPCS,999,RC,8022449,CDM,,,,OUTPATIENT,,, 296.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 251.60,,OUTPCT LIMIT, 197.91,OTHER, 127.82, 290.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47453,99283 EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY TECH FEE,99283,HCPCS,450,RC,8345560,CDM,,,25,OUTPATIENT,,, 657.34, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 558.74,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47454,99283 - LEVEL 3,99283,HCPCS,450,RC,2644299,CDM,,,25,OUTPATIENT,,, 657.34, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 558.74,,OUTPCT LIMIT, 369.55,OTHER, 203.96, 644.19,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47455,99283 EMERGENCY DEPT VISIT LEVEL 3 PROFEE,99283,HCPCS,960,RC,8042519,CDM,,,,OUTPATIENT,,, 340.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 289.00,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47456,99283 INTERMEDIATE SERVICE PROFEE,99283,HCPCS,999,RC,8022450,CDM,,,,OUTPATIENT,,, 340.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 289.00,,OUTPCT LIMIT, 247.74,OTHER, 150.14, 333.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47457,99284 EMERGENCY DEPARTMENT VISIT LEVEL 4,99284,HCPCS,450,RC,8040689,CDM,,,25,OUTPATIENT,,, 1031.07, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 876.41,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47458,99284 - LEVEL 4,99284,HCPCS,450,RC,2644300,CDM,,,25,OUTPATIENT,,, 1031.07, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 876.41,,OUTPCT LIMIT, 580.80,OTHER, 324.71, 1010.45,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47459,99284 EMERGENCY DEPT VISIT LEVEL 4 PROFEE,99284,HCPCS,960,RC,8042520,CDM,,,,OUTPATIENT,,, 421.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 357.85,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47460,99284 EXTENDED SERVICE PROFEE,99284,HCPCS,999,RC,8022451,CDM,,,,OUTPATIENT,,, 421.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 357.85,,OUTPCT LIMIT, 332.53,OTHER, 185.91, 412.58,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47461,99285 EMERGENCY DEPT VISIT HIGH SEVERITYANDTHREAT FUNCJ TECH FEE,99285,HCPCS,450,RC,8345561,CDM,,,25,OUTPATIENT,,, 1719.78, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1461.81,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47462,99285 - LEVEL 5,99285,HCPCS,450,RC,2644301,CDM,,,25,OUTPATIENT,,, 1719.78, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1461.81,,OUTPCT LIMIT, 954.02,OTHER, 479.76, 1685.38,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47463,99285 EMERGENCY DEPT VISIT LEVEL 5 PROFEE,99285,HCPCS,960,RC,8042521,CDM,,,,OUTPATIENT,,, 501.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 425.85,,OUTPCT LIMIT, 429.06,OTHER, 221.24, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47464,99291 - CRITICAL CARE FIRST HOUR,99291,HCPCS,450,RC,8078250,CDM,,,,OUTPATIENT,,, 2750.78, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2338.16,,OUTPCT LIMIT, 1514.86,OTHER, 720.78, 2695.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47465,99292 - CRITICAL CARE ADDL 30 MIN,99292,HCPCS,450,RC,8078251,CDM,,,,OUTPATIENT,,, 1008.41, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 857.15,,OUTPCT LIMIT, 646.30,OTHER, 433.62, 988.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47466,99358 PROLONGED SERVICES INDIRECT CONTACT FIRST HOUR,99358,HCPCS,521,RC,8040725,CDM,,,,OUTPATIENT,,, 30.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 25.50,,OUTPCT LIMIT, 19.23,OTHER, 12.90, 29.40,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47467,99374 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 15-29 MIN,99374,HCPCS,521,RC,8040730,CDM,,,,OUTPATIENT,,, 167.45, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 142.33,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47468,99375 CARE PLAN OVERSIGHT HOME HEALTH PATIENT 30+ MIN,99375,HCPCS,521,RC,8040731,CDM,,,,OUTPATIENT,,, 167.45, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 142.33,,OUTPCT LIMIT, 107.32,OTHER, 72.00, 164.10,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47469,99381 PREVENTIVE EVALUATION NEW PT < 1 YR,99381,HCPCS,521,RC,8040736,CDM,,,,OUTPATIENT,,, 263.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 223.98,,OUTPCT LIMIT, 167.97,OTHER, 113.31, 258.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47470,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,99382,HCPCS,521,RC,8040737,CDM,,,,OUTPATIENT,,, 274.55, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.37,,OUTPCT LIMIT, 173.37,OTHER, 118.06, 269.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47471,99383 PREVENTIVE EVALUATION NEW PT 5-11 YRS,99383,HCPCS,521,RC,8040738,CDM,,,,OUTPATIENT,,, 286.45, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 243.48,,OUTPCT LIMIT, 179.18,OTHER, 123.17, 280.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47472,99384 PREVENTIVE EVALUATION NEW PT 12-17 YRS,99384,HCPCS,521,RC,8040739,CDM,,,,OUTPATIENT,,, 323.85, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 275.27,,OUTPCT LIMIT, 197.44,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47473,99385 PREVENTIVE EVALUATION NEW PT 18-39 YRS,99385,HCPCS,521,RC,8040740,CDM,,,,OUTPATIENT,,, 314.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 267.33,,OUTPCT LIMIT, 192.88,OTHER, 135.24, 308.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47474,99386 PREVENTIVE EVALUATION NEW PT 40-64 YRS,99386,HCPCS,521,RC,8416711,CDM,,,,OUTPATIENT,,, 362.95, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 308.51,,OUTPCT LIMIT, 232.62,OTHER, 156.07, 355.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47475,99387 PREVENTIVE EVALUATION NEW PT 65+ YRS,99387,HCPCS,521,RC,8040742,CDM,,,,OUTPATIENT,,, 394.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 335.24,,OUTPCT LIMIT, 252.78,OTHER, 169.59, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47476,99391 PREVENTIVE EVALUATION ESTABLISHED PT < 1 YR,99391,HCPCS,521,RC,8040743,CDM,,,,OUTPATIENT,,, 237.15, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 201.58,,OUTPCT LIMIT, 155.10,OTHER, 101.97, 232.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47477,99392 PREVENTIVE EVALUATION ESTABLISHED PT 1-4 YRS,99392,HCPCS,521,RC,8040744,CDM,,,,OUTPATIENT,,, 253.30, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 215.31,,OUTPCT LIMIT, 162.99,OTHER, 108.92, 248.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47478,99394 PREVENTIVE EVALUATION ESTABLISHED PT 12-17 YRS,99394,HCPCS,521,RC,8040746,CDM,,,,OUTPATIENT,,, 276.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 234.81,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47479,99394 PREVENTIVE EVAL EST PT. 12-17 YEAR AGE,99394,HCPCS,521,RC,8284469,CDM,,,,OUTPATIENT,,, 276.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 234.81,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47480,99394 PERIODIC COMPREHENSIVE MEDICINE AGES 12-17 LVL 4 CHARGE,99394,HCPCS,521,RC,8327022,CDM,,,,OUTPATIENT,,, 276.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 234.81,,OUTPCT LIMIT, 174.20,OTHER, 118.79, 270.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47481,99395 PREVENTIVE EVALUATION ESTABLISHED PT 18-39 YRS,99395,HCPCS,521,RC,8040747,CDM,,,,OUTPATIENT,,, 282.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 239.87,,OUTPCT LIMIT, 177.10,OTHER, 121.35, 276.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47482,99396 PREVENTIVE EVALUATION ESTABLISHED PT 40-64 YRS,99396,HCPCS,521,RC,8040748,CDM,,,,OUTPATIENT,,, 300.90, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 255.77,,OUTPCT LIMIT, 192.85,OTHER, 129.39, 294.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47483,99397 PREVENTIVE EVALUATION ESTABLISHED PT 65+ YRS,99397,HCPCS,521,RC,8040749,CDM,,,,OUTPATIENT,,, 323.85, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 275.27,,OUTPCT LIMIT, 207.56,OTHER, 139.26, 317.37,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47484,99401 PREVENTIVE MEDICINE COUNSELING APPROX 15 MIN,99401,HCPCS,521,RC,8040750,CDM,,,,OUTPATIENT,,, 86.70, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 73.70,,OUTPCT LIMIT, 55.57,OTHER, 37.28, 84.97,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47485,99402 PREVENTIVE MEDICINE COUNSELING APPROX 30 MIN,99402,HCPCS,521,RC,8040751,CDM,,,,OUTPATIENT,,, 148.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 126.44,,OUTPCT LIMIT, 95.34,OTHER, 63.96, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47486,99403 PREVENTIVE MEDICINE COUNSELING APPROX 45 MIN,99403,HCPCS,521,RC,8040752,CDM,,,,OUTPATIENT,,, 70.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 59.50,,OUTPCT LIMIT, 44.86,OTHER, 30.10, 68.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47487,99404 PREVENTIVE MEDICINE COUNSELING APPROX 60 MIN,99404,HCPCS,521,RC,8040753,CDM,,,,OUTPATIENT,,, 266.05, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 226.14,,OUTPCT LIMIT, 170.52,OTHER, 114.40, 260.73,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47488,99406- SMOKING AND TOBACCO USE CESSATION VISIT:INTERMEDIATE GREATER THAN 3 MIN,99406,HCPCS,521,RC,8198509,CDM,,,,OUTPATIENT,,, 52.88, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 44.95,,OUTPCT LIMIT, 33.14,OTHER, 22.74, 51.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47489,99407- SMOKING AND TOBACCO USE CESSATION VISIT: INTENSIVE GREATER THAN 10 MIN,99407,HCPCS,521,RC,8198508,CDM,,,,OUTPATIENT,,, 65.45, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 55.63,,OUTPCT LIMIT, 39.28,OTHER, 28.14, 64.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47490,99408 ALCOHOL/SUBSTANCE ABUSE STRUCTURED SCREEN 15-30 MIN,99408,HCPCS,521,RC,8040756,CDM,,,,OUTPATIENT,,, 94.38, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 80.22,,OUTPCT LIMIT, 60.49,OTHER, 40.58, 92.49,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47491,99450 BASIC LIFE OR DISABILITY EXAM,99450,HCPCS,521,RC,8040764,CDM,,,,OUTPATIENT,,, 22.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 18.70,,OUTPCT LIMIT, 14.10,OTHER, 9.46, 21.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47492,99455 DOT PHYSICAL,99455,HCPCS,521,RC,8971076,CDM,,,,OUTPATIENT,,, 22.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 18.70,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47493,99455 WORK RELATED OR MEDICAL DISABILITY EXAM,99455,HCPCS,521,RC,8040765,CDM,,,,OUTPATIENT,,, 148.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 126.44,,OUTPCT LIMIT, 54.72,OTHER, 9.46, 145.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47494,99495 TRANS CARE MGMT 14 DAY DISCH,99495,HCPCS,521,RC,8467247,CDM,,,,OUTPATIENT,,, 255.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 216.75,,OUTPCT LIMIT, 148.65,OTHER, 101.33, 249.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47495,99496 TRANS CARE MGMT 7 DAY DISCH,99496,HCPCS,521,RC,8467246,CDM,,,,OUTPATIENT,,, 275.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.75,,OUTPCT LIMIT, 166.04,OTHER, 118.25, 269.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47496,A0425 GROUND MILEAGE TECHFEE,A0425,HCPCS,540,RC,8023486,CDM,,,,OUTPATIENT,,, 12.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 10.84,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47497,AMBULANCE MILEAGE,A0425,HCPCS,540,RC,8320688,CDM,,,,OUTPATIENT,,, 12.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 10.84,,OUTPCT LIMIT, 8.17,OTHER, 5.48, 12.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47498,A0426 ALS NONEMERGENCY,A0426,HCPCS,540,RC,8023487,CDM,,,,OUTPATIENT,,, 385.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 327.25,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47499,ALS LEVEL 1 NON-EMERGENCY,A0426,HCPCS,540,RC,8533597,CDM,,,,OUTPATIENT,,, 385.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 327.25,,OUTPCT LIMIT, 350.13,OTHER, 165.55, 680.93,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47500,ALS LEVEL 1 EMERGENCY,A0427,HCPCS,540,RC,8533599,CDM,,,,OUTPATIENT,,, 607.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 515.95,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47501,A0427 ALS1-EMERGENCY TECHFEE,A0427,HCPCS,540,RC,8023488,CDM,,,,OUTPATIENT,,, 607.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 515.95,,OUTPCT LIMIT, 553.11,OTHER, 261.01, 1078.14,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47502,A0428 BLS TECHFEE,A0428,HCPCS,540,RC,8023489,CDM,,,,OUTPATIENT,,, 355.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 301.75,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47503,BLS NON-EMERGENCY,A0428,HCPCS,540,RC,8532428,CDM,,,,OUTPATIENT,,, 355.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 301.75,,OUTPCT LIMIT, 308.45,OTHER, 152.65, 567.43,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47504,BLS EMERGENCY,A0429,HCPCS,540,RC,8533601,CDM,,,,OUTPATIENT,,, 512.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 435.20,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47505,A0429 BLS-EMERGENCY TECHFEE,A0429,HCPCS,540,RC,8023490,CDM,,,,OUTPATIENT,,, 512.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 435.20,,OUTPCT LIMIT, 466.19,OTHER, 220.16, 907.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47506,ALS LEVEL 2 EMERGENCY OR NON-EMERGENCY,A0433,HCPCS,540,RC,8533603,CDM,,,,OUTPATIENT,,, 878.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 746.30,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47507,A0433 ALS 2 TECHFEE,A0433,HCPCS,540,RC,8023491,CDM,,,,OUTPATIENT,,, 878.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 746.30,,OUTPCT LIMIT, 562.72,OTHER, 377.54, 860.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47508,A0434 SPECIALTY CARE TRANSPORT,A0434,HCPCS,540,RC,8612052,CDM,,,,OUTPATIENT,,, 975.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 828.75,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47509,SPECIALITY CARE TRANSPORT,A0434,HCPCS,540,RC,8533605,CDM,,,,OUTPATIENT,,, 975.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 828.75,,OUTPCT LIMIT, 624.89,OTHER, 419.25, 955.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47510,A0998 AMBULANCE RESPONSE/TREATMENT TECHFEE,A0998,HCPCS,540,RC,8023492,CDM,,,,OUTPATIENT,,, 136.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 115.60,,OUTPCT LIMIT, 87.16,OTHER, 58.48, 133.28,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47511,VIST TC99 MEDRONATE,A9503,HCPCS,343,RC,9250360,CDM,,,TC,OUTPATIENT,,, 64.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 54.40,,OUTPCT LIMIT, 41.02,OTHER, 27.52, 62.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47512,VIST TL-201,A9505,HCPCS,343,RC,9562111,CDM,,,TC,OUTPATIENT,,, 75.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 63.75,,OUTPCT LIMIT, 48.07,OTHER, 32.25, 73.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47513,MRI BREAST W/ + W/O CONTRAST LEFT,C8905,HCPCS,610,RC,8044395,CDM,,,TC|LT,OUTPATIENT,,, 2996.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2546.60,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47514,MRI BREAST W/ + W/O CONTRAST RIGHT,C8905,HCPCS,610,RC,8044397,CDM,,,TC|RT,OUTPATIENT,,, 2996.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2546.60,,OUTPCT LIMIT, 1648.47,OTHER, 779.04, 2936.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47515,MRI BREAST W/ + W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168802,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2771.85,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47516,MRI BREAST W/O CONTRAST BILATERAL,C8908,HCPCS,610,RC,1168814,CDM,,,TC|50,OUTPATIENT,,, 3261.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2771.85,,OUTPCT LIMIT, 1777.88,OTHER, 779.04, 3195.78,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47517,MRA SPINE CERVICAL W/O CONTRAST,C8932,HCPCS,610,RC,8073845,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1955.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47518,MRA SPINE THORACIC W/O CONTRAST˙,C8932,HCPCS,610,RC,8073722,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1955.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47519,MRA SPINE LUMBAR W/O CONTRAST˙,C8932,HCPCS,610,RC,8073716,CDM,,,TC,OUTPATIENT,,, 2300.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1955.00,,OUTPCT LIMIT, 1244.21,OTHER, 508.57, 2254.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47520,MRA UPPER EXTREMITY W/O CONTRAST RIGHT,C8935,HCPCS,610,RC,1168725,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1700.00,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47521,MRA UPPER EXTREMITY W/O CONTRAST LEFT,C8935,HCPCS,610,RC,1168722,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1700.00,,OUTPCT LIMIT, 1097.72,OTHER, 508.57, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47522,MRA UPPER EXTREMITY W/ + W/O CNT RIGHT,C8936,HCPCS,610,RC,1168707,CDM,,,TC|RT,OUTPATIENT,,, 2000.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1700.00,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47523,MRA UPPER EXTREMITY W/ + W/O CNT LEFT,C8936,HCPCS,610,RC,1168704,CDM,,,TC|LT,OUTPATIENT,,, 2000.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1700.00,,OUTPCT LIMIT, 1162.11,OTHER, 779.04, 1960.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47524,C9290 BUPIVACAINE 1 MG,C9290,HCPCS,636,RC,8113621,CDM,,,,BOTH,1,ME, 19.14, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 16.27,,OUTPCT LIMIT, 9.74,OTHER, 1.66, 18.76,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47525,G0008 ADMIN OF INFLUENZA VACCINE CHARGE,G0008,HCPCS,771,RC,8237788,CDM,,,,OUTPATIENT,,, 112.66, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 95.76,,OUTPCT LIMIT, 63.90,OTHER, 37.34, 110.41,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47526,G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE,G0009,HCPCS,521,RC,8040786,CDM,,,,OUTPATIENT,,, 6.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 5.10,,OUTPCT LIMIT, 11.82,OTHER, 2.58, 37.34,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47527,G0101 CERVICAL OR VAGINAL CANCER SCREENING PELVIC AND CLINICAL BREAST EXAM,G0101,HCPCS,510,RC,8040787,CDM,,,,OUTPATIENT,,, 90.10, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 76.59,,OUTPCT LIMIT, 57.75,OTHER, 38.74, 88.30,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47528,G0102 PROSTATE CANCER SCREENING DIGITAL RECTAL EXAMINATION,G0102,HCPCS,521,RC,8040567,CDM,,,,OUTPATIENT,,, 46.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 39.74,,OUTPCT LIMIT, 29.96,OTHER, 20.10, 45.82,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47529,PSA SCRN,G0103,HCPCS,300,RC,4123035,CDM,,,,OUTPATIENT,,, 165.31, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 140.51,,OUTPCT LIMIT, 88.75,OTHER, 33.71, 162.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47530,G0103 PROSTATE CANCER SCREENING PROSTATE SPECIFIC ANTIGEN TEST,G0103,HCPCS,521,RC,8040568,CDM,,,QW,OUTPATIENT,,, 104.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 88.40,,OUTPCT LIMIT, 58.81,OTHER, 33.71, 101.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47531,G0402 INITIAL PREVENTIVE PHYSICAL (WELCOME TO MEDICARE),G0402,HCPCS,521,RC,8040801,CDM,,,,OUTPATIENT,,, 391.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 332.35,,OUTPCT LIMIT, 250.60,OTHER, 168.13, 383.18,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47532,G0438 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0438,HCPCS,521,RC,8040807,CDM,,,,OUTPATIENT,,, 394.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 335.24,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47533,G0439 ANNUAL WELLNESS VISIT INCLUDES A PERSONALIZED PREVENTION PLAN,G0439,HCPCS,521,RC,8040808,CDM,,,,OUTPATIENT,,, 394.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 335.24,,OUTPCT LIMIT, 231.89,OTHER, 165.06, 386.51,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47534,G0442 ANNUAL ALCOHOL MISUSE SCREENING 15 MINUTES,G0442,HCPCS,521,RC,8040809,CDM,,,,OUTPATIENT,,, 42.50, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 36.13,,OUTPCT LIMIT, 35.44,OTHER, 18.28, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47535,G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE 15 MIN,G0443,HCPCS,521,RC,8040810,CDM,,,,OUTPATIENT,,, 61.20, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 52.02,,OUTPCT LIMIT, 44.57,OTHER, 26.32, 61.69,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47536,G0511 RHC CHRONIC CARE MANAGEMENT,G0511,HCPCS,521,RC,8302521,CDM,,,,OUTPATIENT,,, 68.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 57.80,,OUTPCT LIMIT, 43.58,OTHER, 29.24, 66.64,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47537,H0050 ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,450,RC,9999374,CDM,,,,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47538,J0171 EPIPEN ADULT (EPINEPHRINE 0.3MG IM INJECTABLE KIT),J0171,HCPCS,636,RC,8390029,CDM,,,,BOTH,.3,ME, 259.80, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 220.83,,OUTPCT LIMIT, 166.51,OTHER, 111.71, 254.60,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47539,J0500 D BENTYL 20 MG 12 ML,J0500,HCPCS,636,RC,8198343,CDM,,,,BOTH,20,ME, 93.77, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 79.70,,OUTPCT LIMIT, 60.10,OTHER, 40.32, 91.89,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47540,J0690 INJECTION CEFAZOLIN SODIUM 500 MG,J0690,HCPCS,636,RC,8044771,CDM,,,,BOTH,500,ME, 7.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 6.53,,OUTPCT LIMIT, 4.92,OTHER, 3.30, 7.53,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47541,J0696 INJECTION CEFTRIAXONE SODIUM PER 250 MG,J0696,HCPCS,636,RC,8044772,CDM,,,,BOTH,250,ME, 7.44, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 6.32,,OUTPCT LIMIT, 4.77,OTHER, 3.20, 7.29,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47542,J1010 INJECTION METHYLPREDNISOLONE ACETATE PER 1 MG 80 MG [THMH],J1010,HCPCS,636,RC,8061143,CDM,,,,BOTH,1,ME, 20.32, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 17.27,,OUTPCT LIMIT, 13.02,OTHER, 8.74, 19.91,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47543,J1050 INJ MEDROXYPROGESTERONE ACETATE 1 MG,J1050,HCPCS,636,RC,8044732,CDM,,,,BOTH,1,ME, 210.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 178.50,,OUTPCT LIMIT, 134.59,OTHER, 90.30, 205.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47544,J1100 INJECTION DEXAMETHASONE SODIUM PHOSPHATE 1MG,J1100,HCPCS,636,RC,8044734,CDM,,,,BOTH,1,ME, 2.12, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1.80,,OUTPCT LIMIT, 1.36,OTHER, .91, 2.08,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47545,J1200 INJECTION DIPHENHYDRAMINE HCL UP TO 50 MG,J1200,HCPCS,636,RC,8044736,CDM,,,,BOTH,50,ME, 3.28, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2.79,,OUTPCT LIMIT, 2.10,OTHER, 1.41, 3.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47546,J1630 INJECTION HALOPERIDOL UP TO 5 MG,J1630,HCPCS,636,RC,8044773,CDM,,,,BOTH,5,ME, 40.43, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 34.37,,OUTPCT LIMIT, 25.91,OTHER, 17.38, 39.62,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47547,J1650 INJECTION ENOXAPARIN SODIUM 100 MG,J1650,HCPCS,636,RC,8453813,CDM,,,,BOTH,100,ME, 145.11, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 123.34,,OUTPCT LIMIT, 93.00,OTHER, 62.40, 142.21,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47548,J1885 INJECTION KETOROLAC TROMETHAMINE PER 15 MG,J1885,HCPCS,636,RC,8044738,CDM,,,,BOTH,15,ME, 2.28, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1.94,,OUTPCT LIMIT, 1.46,OTHER, .98, 2.23,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47549,J1940 INJECTION FUROSEMIDE UP TO 20 MG,J1940,HCPCS,636,RC,8231382,CDM,,,,BOTH,20,ME, 1.60, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1.36,,OUTPCT LIMIT, 1.03,OTHER, .69, 1.57,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47550,J2001 INJECTION LIDOCAINE 10 MG,J2001,HCPCS,636,RC,8113618,CDM,,,,BOTH,10,ME, 8.04, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 6.83,,OUTPCT LIMIT, 5.15,OTHER, 3.46, 7.88,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47551,J2360 INJECTION ORPHENADRINE CITRATE UP TO 60 MG,J2360,HCPCS,636,RC,8044776,CDM,,,,BOTH,60,ME, 17.88, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 15.20,,OUTPCT LIMIT, 11.46,OTHER, 7.69, 17.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47552,J2405 INJECTION ONDANSETRON HYDROCHLORIDE PER 1 MG,J2405,HCPCS,636,RC,8044743,CDM,,,,BOTH,1,ME, 6.84, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 5.81,,OUTPCT LIMIT, 4.38,OTHER, 2.94, 6.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47553,J2550 INJECTION PROMETHAZINE HCL UP TO 50 MG,J2550,HCPCS,636,RC,8044744,CDM,,,,BOTH,50,ME, 4.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3.40,,OUTPCT LIMIT, 2.56,OTHER, 1.72, 3.92,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47554,J2919 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE 5 MG [THMH],J2919,HCPCS,636,RC,8044747,CDM,,,,BOTH,5,ME, 11.68, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 9.93,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47555,J2920 INJECTION METHYLPREDNISOLONE SODIUM SUCCINATE UP TO 40 MG,J2919,HCPCS,636,RC,8044746,CDM,,,,BOTH,40,ME, 13.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 11.05,,OUTPCT LIMIT, 7.91,OTHER, 5.02, 12.74,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47556,J3030 INJECTION SUMATRIPTAN SUCCINATE 6 MG,J3030,HCPCS,636,RC,8140013,CDM,,,,BOTH,6,ME, 68.32, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 58.07,,OUTPCT LIMIT, 43.79,OTHER, 29.38, 66.95,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47557,J3301 INJECTION TRIAMCINOLONE ACETONIDE NOT OTHERWISE SPECIFIED 10 MG,J3301,HCPCS,636,RC,8044748,CDM,,,,BOTH,10,ME, 35.92, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 30.53,,OUTPCT LIMIT, 23.02,OTHER, 15.45, 35.20,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47558,J3410 INJECTION HYDROXYZINE HCL UP TO 25 MG,J3410,HCPCS,636,RC,8061146,CDM,,,,BOTH,25,ME, 10.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 8.94,,OUTPCT LIMIT, 6.74,OTHER, 4.52, 10.31,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47559,J3420 INJECTION VITAMIN B-12 UP TO 1000MCG,J3420,HCPCS,636,RC,8044750,CDM,,,,BOTH,1,EA, 8.12, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 6.90,,OUTPCT LIMIT, 5.20,OTHER, 3.49, 7.96,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47560,J7297 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (LILETTA) 52 MG,J7297,HCPCS,636,RC,8859847,CDM,,,,BOTH,52,ME, 399.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 339.15,,OUTPCT LIMIT, 575.18,OTHER, 171.57, 1597.44,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47561,J7298 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM 52 MG,J7298,HCPCS,636,RC,8044753,CDM,,,,BOTH,52,ME, 399.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 339.15,,OUTPCT LIMIT, 690.66,OTHER, 171.57, 2082.47,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47562,J7300 INTRAUTERINE COPPER CONTRACEPTIVE,J7300,HCPCS,636,RC,8367341,CDM,,,,BOTH,1,EA, 399.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 339.15,,OUTPCT LIMIT, 656.15,OTHER, 171.57, 1937.50,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47563,J7301 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM (SKYLA) 13.5 MG,J7301,HCPCS,636,RC,8432204,CDM,,,,BOTH,13.5,ME, 399.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 339.15,,OUTPCT LIMIT, 607.70,OTHER, 171.57, 1734.01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47564,J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM INCLUDING IMPLANT AND SUPPLIES,J7307,HCPCS,636,RC,8217426,CDM,,,,BOTH,1,EA, 499.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 424.15,,OUTPCT LIMIT, 735.35,OTHER, 214.57, 2065.06,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47565,J7325 SYNVISC,J7325,HCPCS,636,RC,8794534,CDM,,,,BOTH,1,EA, 855.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 726.75,,OUTPCT LIMIT, 421.89,OTHER, 18.42, 837.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47566,J7613 ALBUTEROL INHALATION SOLUTION NON-COMPOUNDED ADMINISTERED THROUGH DME,J7613,HCPCS,636,RC,8300233,CDM,,,,BOTH,1,ME, 4.80, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 4.08,,OUTPCT LIMIT, 3.08,OTHER, 2.06, 4.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47567,E9764 APH CNV THWD PLSMA ACDA COVID-19 3,P9017,HCPCS,390,RC,8275361,CDM,,,,OUTPATIENT,,, 348.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47568,E2457 LIQUID PLASMA CPD,P9017,HCPCS,390,RC,9320140,CDM,,,,OUTPATIENT,,, 348.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47569,E2684 THAWED PLASMA CPD,P9017,HCPCS,390,RC,7267157,CDM,,,,OUTPATIENT,,, 348.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47570,E2700 THAWED PLASMA CPD CRYO RED,P9017,HCPCS,390,RC,7267160,CDM,,,,OUTPATIENT,,, 348.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47571,E9811 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8275353,CDM,,,,OUTPATIENT,,, 348.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47572,E9803 CONV THAWED PLASMA CP2D COVID-19,P9017,HCPCS,390,RC,9119543,CDM,,,,OUTPATIENT,,, 348.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47573,E9780 CNV THWD PLASMA CPD COVID-19,P9017,HCPCS,390,RC,8203745,CDM,,,,OUTPATIENT,,, 348.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47574,E9765 APH CNV THWD PLSMA ACDA COVID-19 4,P9017,HCPCS,390,RC,8219797,CDM,,,,OUTPATIENT,,, 348.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47575,E9763 APH CNV THWD PLSMA ACDA COVID-19 2,P9017,HCPCS,390,RC,8275362,CDM,,,,OUTPATIENT,,, 348.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47576,E9762 APH CNV THWD PLSMA ACDA COVID-19 1,P9017,HCPCS,390,RC,8275356,CDM,,,,OUTPATIENT,,, 348.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47577,E9752 APH CNV THWD PLSMA ACDA COVID-19,P9017,HCPCS,390,RC,8275354,CDM,,,,OUTPATIENT,,, 348.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47578,E2701 THAWED PLASMA CPD <24H,P9017,HCPCS,390,RC,7267161,CDM,,,,OUTPATIENT,,, 348.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 295.80,,OUTPCT LIMIT, 196.27,OTHER, 110.60, 341.04,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47579,E4543 APH RBC ACDA AS3 LR,P9021,HCPCS,390,RC,7266613,CDM,,,,OUTPATIENT,,, 415.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 352.75,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47580,E0332 RBC CPD AS1 500 LR IRR,P9021,HCPCS,390,RC,7266573,CDM,,,,OUTPATIENT,,, 415.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 352.75,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47581,E0336 RBC CPD AS1 500 LR,P9021,HCPCS,390,RC,7266574,CDM,,,,OUTPATIENT,,, 415.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 352.75,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47582,E0382 RBC CP2D AS3 500 LR,P9021,HCPCS,390,RC,7266659,CDM,,,,OUTPATIENT,,, 415.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 352.75,,OUTPCT LIMIT, 251.75,OTHER, 178.45, 406.70,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47583,E3558 APH PLT WASHED LR 1,P9034,HCPCS,390,RC,7266898,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47584,E3559 APH PLT WASHED LR 2,P9034,HCPCS,390,RC,7266899,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47585,E3560 APH PLT WASHED LR 3,P9034,HCPCS,390,RC,7266900,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47586,E3556 APH PLT WASHED LR,P9034,HCPCS,390,RC,7266897,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47587,E3546 APH PLT WASHED OPEN LR IRR 4,P9034,HCPCS,390,RC,9320129,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47588,E3545 APH PLT WASHED LR IRR 3,P9034,HCPCS,390,RC,7266893,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47589,E3544 APH PLT WASHED LR IRR 2,P9034,HCPCS,390,RC,7266892,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47590,E3543 APH PLT WASHED LR IRR 1,P9034,HCPCS,390,RC,7266891,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47591,E3541 APH PLT WASHED LR IRR,P9034,HCPCS,390,RC,7266890,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47592,E3020 APH PLT ACDA LR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320130,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47593,E3019 APH PLT ACDA LR PLAS RED OPEN 3,P9034,HCPCS,390,RC,9320132,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47594,E3018 APH PLT ACDA LR PLAS RED OPEN 2,P9034,HCPCS,390,RC,9320133,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47595,E3017 APH PLT ACDA LR PLAS RED OPEN 1,P9034,HCPCS,390,RC,9320134,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47596,E3015 APH PLT ACDA LR PLAS RED OPEN,P9034,HCPCS,390,RC,9320135,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47597,E2989 APH PLT ACDA LR IRR PLAS RED OPEN4,P9034,HCPCS,390,RC,9320128,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47598,E2988 APH PLT ACDA LR IRR PLAS RED OPEN3,P9034,HCPCS,390,RC,9320136,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47599,E2987 APH PLT ACDA LR IRR PLAS RED OPEN2,P9034,HCPCS,390,RC,9320137,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47600,E3561 APH PLT WASHED OPEN LR 4,P9034,HCPCS,390,RC,9320131,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47601,E2984 APH PLT ACDA LR IRR PLAS RED OPEN,P9034,HCPCS,390,RC,9320139,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47602,E2986 APH PLT ACDA LR IRR PLAS RED OPEN1,P9034,HCPCS,390,RC,9320138,CDM,,,,OUTPATIENT,,, 1326.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1127.10,,OUTPCT LIMIT, 810.02,OTHER, 570.18, 1299.48,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47603,Q0091 SCREENING PAP SMEAR OBTAINING PREPARING AND CONVEYANCE OF CERVICAL OR VAG,Q0091,HCPCS,521,RC,8040596,CDM,,,,OUTPATIENT,,, 106.25, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 90.31,,OUTPCT LIMIT, 62.01,OTHER, 42.53, 104.13,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47604,S0613 ANNUAL GYN EXAM CLINICAL BREAST EXAM W/O PELVIC EXAM,S0613,HCPCS,521,RC,8044848,CDM,,,,OUTPATIENT,,, 114.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 96.90,,OUTPCT LIMIT, 73.06,OTHER, 49.02, 111.72,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47605,COVID-19 PCR TC,U0002,HCPCS,300,RC,9272503,CDM,,,,OUTPATIENT,,, 100.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 85.00,,OUTPCT LIMIT, 64.18,OTHER, 43.00, 98.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47606,NM NO SHOW ISOTOPE EO,,,250,RC,9106203,CDM,,,,BOTH,1,EA, 500.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 425.00,,OUTPCT LIMIT, 320.46,OTHER, 215.00, 490.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47607,"SPLINT SAM ORANGE/BLUE 36""",,,270,RC,9422951,CDM,,,,OUTPATIENT,,, 42.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 35.70,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47608,DRSG UNNA BOOT 4 X10YDS W/CALAMINE,,,270,RC,9452291,CDM,,,,OUTPATIENT,,, 3.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2.55,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47609,PRESSURE INFUSER CUFF W/MANOM 500ML DISP,,,270,RC,9420777,CDM,,,,OUTPATIENT,,, 35.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 29.75,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47610,POUCH OSTOMY PREMIER HIGH OUTPUT,,,270,RC,9423406,CDM,,,,OUTPATIENT,,, 3.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2.55,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47611,RESUSCITATOR ADULT DMR (AMBUBAG),,,270,RC,9422831,CDM,,,,OUTPATIENT,,, 27.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 22.95,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47612,WAFER DURAHESIVE 2 1/4 SURE FIT,,,270,RC,9423408,CDM,,,,OUTPATIENT,,, 3.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2.55,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47613,"ABDOMINAL BINDER UNIVERSAL 9""H 27-48"" RIB",,,270,RC,9443589,CDM,,,,OUTPATIENT,,, 15.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 12.75,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47614,COLLAR CERVICAL FOAM MED,,,270,RC,9423035,CDM,,,,OUTPATIENT,,, 3.15, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2.68,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47615,PNEUMOCLEAR HEATED HUMIDIFIED SMOKE EVAC TUBE SET INSUFFLATOR,,,270,RC,9423610,CDM,,,,OUTPATIENT,,, 75.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 63.75,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47616,SPLINT METAL WRST/FOREARM MD RT,,,270,RC,9423476,CDM,,,,OUTPATIENT,,, 3.15, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2.68,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47617,BELT RIB MENS SM,,,270,RC,9423029,CDM,,,,OUTPATIENT,,, 4.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 3.84,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47618,TRAY CHEST DRAIN PLEUR-EVAC DRY/WET,,,270,RC,9452292,CDM,,,,OUTPATIENT,,, 101.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 85.85,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47619,DETECTOR CO2 AMBU,,,270,RC,9420800,CDM,,,,OUTPATIENT,,, 6.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 5.10,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47620,IV BLOOD SET Y-TYPE BAXTER,,,270,RC,9423438,CDM,,,,OUTPATIENT,,, 6.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 5.10,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47621,PEAK FLOW METER,,,270,RC,9420803,CDM,,,,OUTPATIENT,,, 183.92, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 156.33,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47622,PASTE OSTOMY 2OZ,,,270,RC,9452293,CDM,,,,OUTPATIENT,,, 6.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 5.10,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47623,HEATED HUMIDIFIED SMOKE EVACUATION SET TUBE,,,270,RC,9423611,CDM,,,,OUTPATIENT,,, 180.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 153.00,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47624,TRAY FOL CATH 18FR W/MTR,,,270,RC,9423303,CDM,,,,OUTPATIENT,,, 58.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 49.30,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47625,TRAY FOL CATH 16FR W/MTR,,,270,RC,9423302,CDM,,,,OUTPATIENT,,, 58.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 49.30,,OUTPCT LIMIT, 27.42,OTHER, 1.29, 180.24,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47626,RT OXYGEN PER DAY CHARGE,,,271,RC,8099198,CDM,,,,OUTPATIENT,,, 332.16, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 282.34,,OUTPCT LIMIT, 212.89,OTHER, 142.83, 325.52,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47627,HOLDER ET TUBE THOMAS PEDIATRIC,,,272,RC,9422881,CDM,,,,OUTPATIENT,,, 121.79, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 103.52,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47628,SUTURE PROLENE 0 FSLX BL MONO 30,,,272,RC,9423577,CDM,,,,OUTPATIENT,,, 75.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 63.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47629,"MESH LAPAROSCOPIC LEFT SELF-FIXATING 15CM X 10CM 5.9""X3.9""",,,272,RC,9423629,CDM,,,,OUTPATIENT,,, 984.63, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 836.94,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47630,IV SET LEVEL 1 BLOOD FLUID WARMER D-100,,,272,RC,9423267,CDM,,,,OUTPATIENT,,, 717.04, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 609.48,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47631,ISOLATION GOWN THUMBS UP XL MICROPOROUS BREATHABLE,,,272,RC,9312108,CDM,,,,OUTPATIENT,,, 9.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 7.65,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47632,PACK BASIC 1 CONVERTER,,,272,RC,9423832,CDM,,,,OUTPATIENT,,, 6.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 5.10,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47633,ABSORBATACK FIXATION DEVICE 5MM SINGLE USE 30 TACKS,,,272,RC,9423609,CDM,,,,OUTPATIENT,,, 101.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 85.85,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47634,CARTER THOMASON CLOSESURE SYSTEM,,,272,RC,9423818,CDM,,,,OUTPATIENT,,, 101.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 85.85,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47635,"HEMOSTAT SURGICEL ABSORBABLE 4"" X 8""",,,272,RC,9423761,CDM,,,,OUTPATIENT,,, 101.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 85.85,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47636,"LITE PLUG 1 PK LARGE PERFIX 1.6"" X 1.9""",,,272,RC,9423627,CDM,,,,OUTPATIENT,,, 101.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 85.85,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47637,"LITE PLUG 1 PK MEDIUM PERFIX 1.3"" X 1.6""",,,272,RC,9423628,CDM,,,,OUTPATIENT,,, 101.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 85.85,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47638,POWER PORT IMPLANTABLE PORT,,,272,RC,9423652,CDM,,,,OUTPATIENT,,, 101.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 85.85,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47639,SYSTEM ENDOSUTURE SUTURE ASSISTANT,,,272,RC,9423635,CDM,,,,OUTPATIENT,,, 101.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 85.85,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47640,ADHESIVE SKIN LIQUID DERMABOND,,,272,RC,9312105,CDM,,,,OUTPATIENT,,, 6.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 5.10,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47641,TROCAR BLADELESS 5MM 100MM,,,272,RC,9325282,CDM,,,,OUTPATIENT,,, 101.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 85.85,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47642,ROTATABLE SNARE MEDIUM OVAL MEDIUM STIFF,,,272,RC,9423454,CDM,,,,OUTPATIENT,,, 102.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 86.70,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47643,CATH FOL 28FR 30ML 2W,,,272,RC,9423333,CDM,,,,OUTPATIENT,,, 71.84, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 61.06,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47644,CATH THORACIC 24FR,,,272,RC,9422911,CDM,,,,OUTPATIENT,,, 71.84, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 61.06,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47645,LAPAROSCOPIC CHOLANGIOGRAPHY SET,,,272,RC,9312113,CDM,,,,OUTPATIENT,,, 75.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 63.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47646,GROUNDING PAD DUAL DISPERSIVE ELECTRODE,,,272,RC,9320169,CDM,,,,OUTPATIENT,,, 137.58, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 116.94,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47647,YANKAUER SUCTION TIP AND TUBE 6 MM X 10FT,,,272,RC,9423206,CDM,,,,OUTPATIENT,,, 3.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2.55,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47648,BLADES CAH 4412D FOR SURGICAL CLIPPERS CAH4413,,,272,RC,9422922,CDM,,,,OUTPATIENT,,, 15.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 12.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47649,DRAIN ROUND CHANNEL SILICONE 10MM FULL,,,272,RC,9423816,CDM,,,,OUTPATIENT,,, 15.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 12.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47650,KITTNER DISSECTOR SINGLE 5MM X 40MM,,,272,RC,9423819,CDM,,,,OUTPATIENT,,, 15.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 12.75,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47651,CATH THORACIC 32FR,,,272,RC,9422913,CDM,,,,OUTPATIENT,,, 18.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 15.30,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47652,VALVE ANTI-REFLUX FILTER,,,272,RC,9422883,CDM,,,,OUTPATIENT,,, 24.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 20.40,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47653,SUTURE MONOCRYL 3-0 PS-2 UND MONO Y497G,,,272,RC,9312110,CDM,,,,OUTPATIENT,,, 3.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2.55,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47654,NEEDLE 18G X 1-1/2 BLUNT FILL,,,272,RC,9423512,CDM,,,,OUTPATIENT,,, 28.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 24.24,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47655,"NEEDLE HYPO 18GX1-1/2""",,,272,RC,9423525,CDM,,,,OUTPATIENT,,, 28.52, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 24.24,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47656,PACK LAP CHOLE (DEPT#175),,,272,RC,9312112,CDM,,,,OUTPATIENT,,, 30.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 25.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47657,RETRIEVER ENDOPOUCH SPEC BAG,,,272,RC,9312111,CDM,,,,OUTPATIENT,,, 30.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 25.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47658,SUTURE 3-0 18IN VICRYL PLUS UND PS-1,,,272,RC,9423535,CDM,,,,OUTPATIENT,,, 30.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 25.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47659,SUTURE ETHLN P-3 NYLON 6-0 BLK MONO 18,,,272,RC,9423568,CDM,,,,OUTPATIENT,,, 30.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 25.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47660,PENCIL ELECTRO ROCKER HOLSTER,,,272,RC,9423645,CDM,,,,OUTPATIENT,,, 3.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2.55,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47661,CUP SPECIMEN 4 OZ STRL W/LABEL SCREW LID,,,272,RC,9320170,CDM,,,,OUTPATIENT,,, 2.99, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2.54,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47662,PACKING NASAL W/STRING 4.5CMX1.5CMX2.,,,272,RC,9423357,CDM,,,,OUTPATIENT,,, 46.49, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 39.52,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47663,PROTEXIS BLUE 8 PI SURGICAL UNDERGLOVE,,,272,RC,9312114,CDM,,,,OUTPATIENT,,, 10.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 8.50,,OUTPCT LIMIT, 60.94,OTHER, 1.29, 964.94,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47664,SPLINT METAL WRST/FOREARM LG RT,,,274,RC,9423475,CDM,,,,OUTPATIENT,,, 3.15, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2.68,,OUTPCT LIMIT, 2.02,OTHER, 1.35, 3.09,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47665,MESH LAPAROSCOPIC RIGHT SELF-FIXATING 15CM X 10CM,,,278,RC,9423630,CDM,,,,OUTPATIENT,,, 501.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 425.85,,OUTPCT LIMIT, 321.10,OTHER, 215.43, 490.98,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47666,HYPERCOAGULABLE PANEL TC,,,300,RC,9282643,CDM,,,,OUTPATIENT,,, 572.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 486.20,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47667,.MORPHOLOGY (VIST),,,300,RC,9357374,CDM,,,,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47668,AEROBIC CULTURE SWAB TC,,,300,RC,9275050,CDM,,,,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47669,C-1-ESTERASE INHIBITOR PANEL TC,,,300,RC,9258419,CDM,,,,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47670,HERPES VIRUS 1 AND 2 DETECTION AND TYPIN,,,300,RC,9282680,CDM,,,,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47671,MISC REF TEST (OTHER REF LAB) TC,,,300,RC,9312532,CDM,,,,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47672,OBSTETRIC PANEL TC,,,300,RC,9313601,CDM,,,,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47673,PROT/CREA RATIOU TC,,,300,RC,9337158,CDM,,,,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, 35.99,OTHER, .01, 560.56,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47674,VIST TC-MIBI,,,343,RC,9620509,CDM,,,TC,OUTPATIENT,,, 34.03, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 28.93,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47675,VIST TC- MAA,,,343,RC,9618023,CDM,,,TC,OUTPATIENT,,, 152.19, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 129.36,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47676,VIST TC-DTPA,,,343,RC,9618025,CDM,,,TC,OUTPATIENT,,, 142.64, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 121.24,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47677,VIST I-123,,,343,RC,9618027,CDM,,,TC,OUTPATIENT,,, 93.19, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 79.21,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47678,VIST TC-SC,,,343,RC,9618019,CDM,,,TC,OUTPATIENT,,, 85.54, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 72.71,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47679,VIST TC-MAG3,,,343,RC,9618029,CDM,,,TC,OUTPATIENT,,, 260.29, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 221.25,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47680,VIST LEXISCAN (10 PK),,,343,RC,9618017,CDM,,,TC,OUTPATIENT,,, 7605.70, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 6464.85,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47681,VIST TC-MDP,,,343,RC,9618021,CDM,,,TC,OUTPATIENT,,, 45.22, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 38.44,,OUTPCT LIMIT, 674.46,OTHER, 14.63, 7453.59,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47682,COLONOSCOPY STOMA,,,361,RC,7632987,CDM,,,,OUTPATIENT,,, 1780.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47683,ENDOSCOPIC TATTOOING,,,361,RC,8252944,CDM,,,,OUTPATIENT,,, 1780.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47684,ESOPHAGOGASTRODUODENOSCOPY BIOPSY,,,361,RC,7633304,CDM,,,,OUTPATIENT,,, 1780.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47685,ESOPHAGOGASTRODUODENOSCOPY EXCISION LESION,,,361,RC,7633307,CDM,,,,OUTPATIENT,,, 1780.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47686,ESOPHAGOGASTRODUODENOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7633308,CDM,,,,OUTPATIENT,,, 1780.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47687,ESOPHAGOGASTRODUODENOSCOPY WITH PEG PLACEMENT,,,361,RC,7633314,CDM,,,,OUTPATIENT,,, 1780.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47688,EGD AND COLONOSCOPY,,,361,RC,8266277,CDM,,,,OUTPATIENT,,, 2400.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 2040.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47689,COLONOSCOPY POLYPECTOMY STOMA,,,361,RC,7632986,CDM,,,,OUTPATIENT,,, 1780.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47690,COLONOSCOPY FOREIGN BODY REMOVAL STOMA,,,361,RC,7632985,CDM,,,,OUTPATIENT,,, 1780.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47691,COLONOSCOPY FOREIGN BODY REMOVAL,,,361,RC,7632984,CDM,,,,OUTPATIENT,,, 1780.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47692,COLONOSCOPY EXCISION LESION,,,361,RC,7632983,CDM,,,,OUTPATIENT,,, 1780.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47693,COLONOSCOPY BIOPSY STOMA,,,361,RC,7632977,CDM,,,,OUTPATIENT,,, 1780.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47694,COLONOSCOPY BIOPSY,,,361,RC,7632976,CDM,,,,OUTPATIENT,,, 1780.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1513.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47695,ESOPHAGOGASTRODUODENOSCOPY,,,361,RC,7633302,CDM,,,,OUTPATIENT,,, 1400.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1190.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47696,ROOM/BED: SURGERY,,,361,RC,8791817,CDM,,,,OUTPATIENT,,, 1400.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1190.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47697,COLONOSCOPY,,,361,RC,7632975,CDM,,,,OUTPATIENT,,, 1400.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 1190.00,,OUTPCT LIMIT, 1119.99,OTHER, 602.00, 2352.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47698,GENERAL,,,370,RC,1648930,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47699,LOCAL/MAC,,,370,RC,8469799,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47700,MONITORED ANESTHESIA CARE,,,370,RC,1648924,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47701,TIVA,,,370,RC,8113476,CDM,,,,OUTPATIENT,,, 105.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 89.25,,OUTPCT LIMIT, 67.30,OTHER, 45.15, 102.90,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47702,VIST MISC CHARGE,,,400,RC,9716412,CDM,,,TC|26,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47703,97127 OT COGNITIVE FUNCTION 15 MIN CHARGE,,,430,RC,9013331,CDM,,,GO,OUTPATIENT,,, 67.13, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 57.06,,OUTPCT LIMIT, 43.03,OTHER, 28.87, 65.79,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47704,G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE,,,521,RC,8040785,CDM,,,,OUTPATIENT,,, 10.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 8.50,,OUTPCT LIMIT, 6.41,OTHER, 4.30, 9.80,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47705,FULL TRAUMA TEAM ACTIVATION FEE TECHFEE,,,684,RC,8657491,CDM,,,,OUTPATIENT,,, 5800.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 4930.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47706,G0390-911 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102328,CDM,,,,OUTPATIENT,,, 4800.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 4080.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47707,G0390-811 PREACTIVATION TRAUMA RESPONSE,,,684,RC,8102326,CDM,,,,OUTPATIENT,,, 4800.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 4080.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47708,PARTIAL TRAUMA TEAM ACTIVATION. TECH FEE,,,684,RC,8283121,CDM,,,,OUTPATIENT,,, 4800.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 4080.00,,OUTPCT LIMIT, 3236.61,OTHER, 2064.00, 5684.00,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47709,58160-0976-20-VFC - MENINGOCOCCAL GROUP B VACCINE - SUSP-INJ,,,999,RC,9442829,CDM,,,SL,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47710,63361-0243-15-VFC - DIPHTHERIA/HAEM/HEPB/PERTACEL/POLIO/TETAN - SUSP,,,999,RC,9440751,CDM,,,SL,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47711,RT CHARGE PFT,,,999,RC,4613962,CDM,,,,OUTPATIENT,,, 436.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 370.60,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47712,90839 PSYCHOTHERAPY FOR CRISIS FIRST 60 MINUTES,,,999,RC,9365808,CDM,,,,OUTPATIENT,,, 294.22, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 250.09,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47713,90791 PSYCHIATRIC DIAGNOSTIC EVALUATION,,,999,RC,9306248,CDM,,,,OUTPATIENT,,, 303.31, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 257.81,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47714,90847 FAMILY PSYCHOTHERAPY WITH PATIENT 50 MINUTES,,,999,RC,9365811,CDM,,,,OUTPATIENT,,, 247.11, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 210.04,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47715,99382 PREVENTIVE EVALUATION NEW PT 1-4 YRS,,,999,RC,9548371,CDM,,,,OUTPATIENT,,, 274.55, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 233.37,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47716,11604 EXCISION MALIGNANT LESION TRUNK ARMS/LEGS 3.1CM-4.0CM,,,999,RC,9091212,CDM,,,,OUTPATIENT,,, 567.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 481.95,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47717,99213 OFFICE VISIT ESTABLISHED PT. LEVEL 3,,,999,RC,9306244,CDM,,,,OUTPATIENT,,, 173.40, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 147.39,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47718,RELOAD ECHELON FLEX ENDOPATH 3.5MM GRN,,,999,RC,9423786,CDM,,,,OUTPATIENT,,, 101.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 85.85,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47719,99201 OFFICE/OUTPATIENT VISIT - NEW PATIENT LEVEL 1 (10 MIN),,,999,RC,8040647,CDM,,,,OUTPATIENT,,, 101.66, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 86.41,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47720,99202 OFFICE VISIT NEW PT. LEVEL 2,,,999,RC,9306239,CDM,,,,OUTPATIENT,,, 148.75, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 126.44,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47721,COMPRESSION HOSE THIGH MD REG EMBOLISM,,,999,RC,9423234,CDM,,,,OUTPATIENT,,, 17.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 14.45,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47722,90718 TET DIP TOX TO >7Y/O FOR IM USE TECHFEE,,,999,RC,8655878,CDM,,,,OUTPATIENT,,, 28.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 23.80,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47723,00005-2000-10-VFC - PNEUMOCOCCAL 20-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9472529,CDM,,,SL,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47724,00006-4047-41-VFC - ROTAVIRUS VACCINE - SUSP,,,999,RC,9441352,CDM,,,SL,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47725,00006-4093-02-VFC - HEPATITIS B PEDIATRIC VACCINE - SUSP,,,999,RC,9441338,CDM,,,SL,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47726,00006-4095-02-VFC - HEPATITIS A PEDIATRIC VACCINE - SUSP,,,999,RC,9440756,CDM,,,SL,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47727,00006-4121-02-VFC - HUMAN PAPILLOMAVIRUS VACCINE - SUSP-INJ,,,999,RC,9441360,CDM,,,SL,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47728,00006-4171-00-VFC - MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9442830,CDM,,,SL,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47729,58160-0955-09-VFC - MENINGOCOCCAL CONJUGATE VACCINE - KIT,,,999,RC,9441344,CDM,,,SL,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47730,58160-0842-52-VFC - TETANUS/DIPHTH/PERTUSS (TDAP) ADULT/ADOL 5 UNITS-2.5 UNIT,,,999,RC,9472828,CDM,,,SL,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47731,58160-0812-52-VFC - DIPHTHERIA/PERTUSSISACEL/TETANUS/POLIO - SUSP,,,999,RC,9441334,CDM,,,SL,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47732,49281-0511-05-VFC - DIPHTH/HAEMOPHILUS/PERTUSSIS/TETANUS/POLIO - VIAL,,,999,RC,9440753,CDM,,,SL,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47733,00006-4827-00-VFC - VARICELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441363,CDM,,,SL,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47734,00006-4329-03-VFC - PNEUMOCOCCAL 15-VALENT CONJUGATE VACCINE - SUSP,,,999,RC,9441347,CDM,,,SL,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47735,REPORT,,,999,RC,593588,CDM,,,,OUTPATIENT,,, 325.00, .01,ZELIS,ZELIS NETWORK SOLUTIONS, 276.25,,OUTPCT LIMIT, 185.70,OTHER, 7.51, 555.66,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT 47736,00006-4681-00-VFC - MEASLES/MUMPS/RUBELLA VIRUS VACCINE - POWDER-INJ,,,999,RC,9441346,CDM,,,SL,OUTPATIENT,,, .01, .01,ZELIS,ZELIS NETWORK SOLUTIONS, .01,,OUTPCT LIMIT, .01,OTHER, .01, .01,PERCENT OF BILLED CHARGES WITH DRG LIMIT - FLOOR AMOUNT - CEILING AMOUNT